STAFF ONLY - Pre-Return to Work Questionnaire COVID-19

Q1. 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? *

Yes No

Q3. Are you awaiting the results of a COVID-19 test? *

Yes No

Q2. Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? *

Yes No

Q4. In the past 14 days, have you been in contact with a person who is a confirmed or suspected case of COVID-19? *

Yes No

Q.7 Have you been categorised as ‘Very High Risk’ or ‘High Risk’ by the Occupational Health Service (OHS) *

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. *

* 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-19
can 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/

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.

Galway Educate Together Pre-Return to Work Questionnaire COVID-19

Galway Educate Together
Pre-Return to Work Questionnaire COVID-19