Screening and Declaration Form

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Please complete this form before you come back to Mass at our Parish for the first time since Covid Lockdown.

Email *

Names of people in my household attending the public worship (including me). Must include full NAME of each person attending. *

Email address to contact should infection occur *

Cell Number to contact should infection occur *

Address *

Temperature will be taken before entry and must be lower than 37,4*C. I understand that if the temperature is 37,4*C or higher of any person in my household attending mass, we must be isolated and counselled as to monitoring and testing. *

I understand

I do not accept this

I will social distance (2m) outside of church waiting for my turn to be screened and at all times during and after public worship. I must wear a face mask over my mouth and nose the entire time in church. For communion the priest will come to the pew to place the host into my left hand. I may briefly remove the face mask with my right hand to place the host into my mouth. *

I understand

I do not accept this

On entering the church I will receive hand sanitizer and I will rub my hands for 20 sec before entering the church. I must bring my own hand sanitizer and paper towels or wipes. Before I leave after prayer after mass I will wipe down the pews where ever I touched them (usher will spray disinfectant). *

I understand

I do not accept this

I will come to mass directly from home. I will not run errands beforehand, i.e. shopping. *

I understand

I do not accept this

Screening- If the answers to any of the screening questions below is positive, I may not enter the Church, must be isolated, and counselled as to monitoring and testing. *

I understand

I do not accept this

In the past 7 days have you or a member of your household experienced any of the following symptoms? *

Fever

Cough

Sore throat

Shortness of breath

Difficulty in breathing

Body aches

Loss of smell

Loss of taste

Nausea

Vomiting

Diarrhoea

Fatigue, weakness or tiredness

None of above

Required

In the last 14 days in your community, were you in close contact with or living with any of the following: (close contact means you were face-to-face i.e. less than 1 m with the person or you were in a close space, car, taxi or house for more than 15 min) *

A person with flu-like symptoms

A person with confirmed Covid-19 virus

A person under investigation for Covid-19

None of above

Required

In the last 14 days have you or anyone in your household been admitted to a hospital with severe pneumonia? *

YES

In the last 14 days have you or anyone in your household worked in or attended a health care facility where Covid-19 patients are treated? *

YES

Undertaking to Give Notice: I and everyone in my household have passed all the screening above. I undertake that should I or anyone in my household begin to experience any of these symptoms I will immediately notify the Parish Priest. I also understand that this is an important moral and legal obligation placed on me for the good of the community. I have read the above procedures and agree to comply with all health and safety measures. I am aware of, and accept all the risks associated with the pandemic: and I shall hold the Church, its employees and volunteers harmless, due to my voluntary attendance of public worship. *

YES, I have read, agree, undertake, understand and accept.

Procedures for the admitting of parishioners back into Church for Mass