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September 2021 Pre-Return to Work Form COVID-19
Rathfarnham Educate Together National School. Principal: Maeve McCarthy.
This questionnaire must be completed by staff in advance of returning to work.
If the answer is Yes to any of the below questions, you are advised to seek medical advice before returning to work.
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Date:
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Do you have symptoms of cough, fever, high temperature (38 degrees C or above), difficulty breathing, loss or change in your sense of smell or taste now or in the past 14 days?
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Yes
No
Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?
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Yes
No
Are you awaiting the results of a COVID-19 test?
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Yes
No
In the past 14 days, have you been in contact with a person who is a confirmed or suspected case of COVID-19?
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Yes
No
Have you been advised to self-isolate at this time?
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Yes
No
Have you been advised to restrict your movements at this time?
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Yes
No
Have you been categorised as ‘Very High Risk’ or ‘High Risk’ by the Occupational Health Service (OHS)?
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Yes
No
Please provide details below of any other circumstances relating to COVID-19, not included in the above, which may need to be considered to allow your safe return to work e.g. returning from travel abroad.
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Your answer
* If your situation changes after you complete and submit this Return to Work Form, please inform your employer. ** Further information on people at very high risk (extremely vulnerable) or high risk from COVID-19can be found at link:
https://www2.hse.ie/conditions/coronavirus/people-at-higher-risk.html
. *** Details of current arrangements for travel overseas can be found set out at
https://www.gov.ie/en/publication/77952-government-advice-on-international-travel/I
confirm, to the best of my knowledge that I have no symptoms of COVID-19, am not self-isolating or awaiting results of a COVID-19 test and have not been advised to restrict my movements. Please note: The school is collecting this sensitive personal data for the purposes of maintaining safety within the workplace in light of the COVID-19 pandemic. The legal basis for collecting this data is based on vital public health interests and maintaining occupational health and this data will be held securely in line with our retention policy.
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A copy of your responses will be emailed to the address you provided.
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