The Carlow Academy

Declaration of Health Form Covid-19 for TEAM members @TCA

In the interest of the Health and Safety of all people onsite at The Carlow Academy I would ask you to fill out this form in an honest and careful manner. If, after filling out this declaration, you or anyone in your family does develop Covid-19 symptoms or are deemed close contacts of a positive case of Covid-19 then please notify me immediately by following public health guidelines.
Full Name*
Mobile Contact Number*
Job Title*
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 10 days?*
Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 10 days?*
Are you awaiting the results of a COVID-19 test?*
In the past 10 days, have you been in contact with a person who is a confirmed or suspected case of COVID-19?*
Have you been advised to self-isolate at this time?*
Have you been advised to restrict your movements at this time?*
Have you been categorised as ‘Very High Risk’ or ‘High Risk’ by the Occupational Health Service (OHS)*
Please note that if you answered YES to any of the questions above then you will be required to self-isolate as per current public health guidelines. We are collecting this sensitive data for the purpose of maintaining safety within The Carlow Academy in light of the Covid-19 pandemic. Please remember to adhere to all health and safety guidelines outlined in The Carlow Academy. Thanking you in advance for your full cooperation.
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.
Privacy Policy Consent*
I agree to the privacy policy.

Declaration of Health Form Covid-19 for TEAM members @TCA

Want To Have A Consistent Routine? Then Become A Member Today

Want To Have A Consistent Routine?

Then Become A Member Today