Return to ( in -person ) Programmes COVID-19 Screening Form 2021
This form is to be used by Participants returning to in- person programmes facilitated by Lisa Kennedy of Calmpaths.ie

DATA PROTECTION NOTIFICATION  
Your personal data is being collected on this form in order to prevent the spread of Covid- 19 and specifically, in order to comply with Irish government safe return, to indoor training and indoor programme, protocols.
The Data Controller for the personal data provided on this form is Calmpaths.ie . The Clampaths.ie Data Protection Officer can be contacted by email at dataprotection@calmpaths.ie - if you have any questions or queries in relation to your personal data.
 Your personal data provided on this form will not be used for any other purposes and will be strictly confidential.
 Info on your rights:  www.gdprandyou.ie. If you would like to make a complaint or report a breach in relation to your personal data, you can do so via the Data Protection Commission's website at www.dataprotection.ie, or by email to info@dataprotection.ie.


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I have read the above screening form and fully understand its contents. I confirm that the details above are true to the best of my knowledge, that I understand the risks involved with participation and that I can opt out at any time. *
Required
Full Name *
Do you believe you may currently have COVID-19? *
Have you had any of the following symptoms of COVID-19 in the past 14 days? *
High Temperature ( i.e Over 37.5 degrees Celsius)
New unexplained shortness of breath *
A new continuous cough *
Loss of sense of smell, taste or distortion of taste *
Do you currently have a headache,  sore throat,  runny nose or sneeze
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If you have answered YES to any of the above questions, you should stay at home and contact your GP by phone for further advice .

If you have answered No to all of the questions you may participate in the indoor classes and programme.

This screening form needs to be completed and submitted once, within a 24 hour period, before participating in these classes and programmes.
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