UCD International Student Health Declaration Form

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UCD International Student Health Declaration Form - 2021

In the interests of the safety of all members of the University community and the wider population, the University requires all incoming students who arrive from outside the island of Ireland to complete the following health declaration form. This requirement complies with the Irish Higher Education sectoral protocol for the arrival of international students.

You are required to submit this form on the day of your departure from your home country / international location, and again at 14 days post-arrival in Ireland.

The information received through this form will be handled by UCD staff only and is being collected for health and safety purposes. Should you feel unwell or display symptoms of Covid-19 please postpone your travel plans and contact your doctor, or if you've arrived in Ireland, please contact the UCD Student Health Centre for further advice: https://www.ucd.ie/stuhealth/services/coronavirusfaqs/

Email *

When are you submitting this form? *

Day of departure from my home country / international location

At the end of 14 days restricted movement in Ireland

First Name *

Family Name *

UCD Student Number *

Email address *

1. Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness, loss of taste or flu like symptoms now or have you had these at any point in the past 14 days? *

Yes

Comment:

2. Have you been diagnosed with confirmed or suspected COVID-19 infection in the past 14 days? *

Yes

Comment:

3. Have you been in close contact with a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. a family member or someone you shared a home with in the past 14 days)? *

Yes

Comment:

4. Have you been advised by a doctor to self-isolate or quarantine in the past 14 days? *

Yes

Comment:

5. Have you been advised by a doctor to cocoon at this time? For further information about "cocooning" please see: https://www2.hse.ie/conditions/coronavirus/people-at-higher-risk.html#very-high-risk *

Yes

Comment:

I confirm that I have responded to the questions above truthfully based on my current condition. I commit to advising the University and Irish health authorities (www.hse.ie) if this situation changes/changed during my travel to Ireland. *

Yes

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