u16 Cobh Pirates RFC: PRE-RUGBY PERSONAL ASSESSMENT DECLARATION

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This form must be completed and submitted to your club/school before each and every rugby activity (e.g. training or match). Should you answer YES to any of these questions, you should NOT attend your club.

Enter the youth player's name: *

Please input the date the player will be attending the Paddocks for training, match or a Club event. *

YYYY

1. Have you been identified by Public Health as a close contact of a confirmed case of COVID-19 in the past 10 days? *

Yes

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

Yes

3. Have you been advised by a doctor to self-isolate or restrict movement at this time? *

Yes

4. Are you feeling unwell, have felt unwell in the past 48 hours or have any common symptom of COVID-19 including, but, not limited to: *

Yes

Fever or high temperature

A new continuous cough

Unexplained breathing difficulties or shortness of breath

Loss or change to your sense of smell or taste

Runny nose

Nasal congestion

Sinus type symptoms

5. Are you currently required to self-isolate/restrict movement due to recent overseas travel? *

Yes

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