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

This questionnaire must be completed by staff and returned 3 days before returning to work.
If the answer is Yes to any of the below questions, you are advised to seek medical advice before returning to work.

Name of School: Galway Educate Together National School

Name of Acting Principal: Deirbhile Ní Scolaí

Please answer Yes or No to the following questions.

Q1. 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 No

Q3. 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

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

Yes No

Q4. Have you been advised by a doctor to self-isolate at this time? *

Yes No

Q.7 Have you been advised to cocoon at this time? Note: if you’re at very high risk (extremely vulnerable) from Covid-19 you may be advised to cocoon. If yes, please liaise with Principal re return to work and follow the agreed DES arrangements for very high risk groups *

Yes No

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 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