Covid Safety Checklist

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Interface Inagh

Name *

Email *

Address *

Phone number *

Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days? *

Yes

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

Yes

Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. lessthan 2m for more than 15 minutes accumulative in 1 day)? *

Yes

Have you been advised by a doctor to self-isolate at this time? *

Yes

Have you been advised by a doctor to cocoon at this time? *

Yes

I confirm that I have responded to the questions above truthfully based on my current condition. I also commit to advising the Executive Director at Interface if this situation changes and I will exclude myself from entering the workspace should I develop COVID-19 Symptoms and seek GP advice while I self-isolate at home. *

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