Pre-Return to School Questionnaire COVID-19 Donaghpatrick National School

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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 school.

Name *

Principals Name *

Today's Date *

YYYY

Do you have symptoms of cough, fever/high temperature (38° or above), difficulty breathing, loss or change in your sense of small or taste now or in the past 14 days? *

Yes

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

Yes

Are you awaiting the results of a COVID-19 test? *

Yes

In the Past 14 days, have you been in contact with a person who is a confirmed or suspected case of COVID-19? Click http://www.hse.ie/coronavirus for up to date information on ‘close contact’ and ‘casual contact’. *

Yes

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

Yes

Have you been advised to restrict your movements at this time? *

Yes

Have you been advised to cocoon at this time? *

Yes

Additional Information

Untitled Title

*If your situation changes after you complete and submit this form, please tell you manager.
** Further information on people at very high rish (extremely vulnerable) or high risk from COVID-19
can be found at www.hse.ie/coronavirus
*** See https://www.dfa.ie/travel/travel-advice/coronavirus/ for up to date travel advice. Note travel
restrictions within the island of Ireland may be subject to domestic Public Health restrictions.

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. Please note: The organisation 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 will be held securely in line with our retention policy. Please type your full name and date to confirm your agreement. *

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