Covid-19 Contact Tracing Log/ Questionnaire

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For School Visitors

Castleconnell National School

Name: *

Phone Number: *

Email Address: *

Date of Visit *

YYYY

Time of Visit *

Time

Was this visit pre-arranged with the Principal? *

Yes

Reason for Visit: *

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

Have you been advised by the HSE that you are a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days? *

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

Have you been advised by your doctor that you are in the very high risk group?If yes, please liaise with Principal re return to work and follow the agreed DES arrangements for very high risk groups *

Yes

Declaration: 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 and to enable the HSE to contact trace when necessary 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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