Community Staff Covid-19 Pre Return to Work Questionnaire for Employees - County Roscommon Disability Support Group

Date of returning to work *

DD/MM/YYYY

Name *

First

Last

Mobile No. *

Email *

Email

Confirm Email

Do you currently have, or have you been diagnosed with confirmed or suspected COVID-19 infection in the last 10 days? *

Yes
No

If YES, continue to self-isolate, i.e., stay indoors and completely avoid contact with other people, including others in your household

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

Yes
No

If YES, continue to self-isolate, i.e., stay indoors and completely avoid contact with other people, including others in your household

As far as you are aware have you been a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days? *

Yes
No

If YES, follow and implement the advice available at https://www2.hse.ie/conditions/covid19/contact-tracing/close-contact/

Are you returning from outside the island of Ireland? *

Yes
No

If YES, follow and implement the advice issued from the Department of the Taoiseach available at https://www.gov.ie/en/publication/77952-government-advice-on-international-travel/#passengers-arriving-into-ireland-from-overseas

Have you experienced any of the following symptoms in the past 14 days? • Fever, Chills, Sweating, Malaise, Aches, Shortness of breath or New/Worsening cough (dry or productive), Sore throat, Loss of taste or smell, Vomiting/Diarrhoea *

Yes
No

If YES to any of the above, please self-isolate and contact your GP for advice.

If you answered Yes to any of the foregoing questions, have you consulted a doctor or other medical practitioner? *

Yes
No
Not Applicable

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

Yes
No

If YES, continue to follow advice received from your GP or HSE.

Have you been advised by a doctor / HSE to restrict your movements at this time? *

Yes
No

If YES, continue to follow advice received from your GP or HSE.

Can you please confirm you have watched RSG’s COVID Housekeeping Video on the website (above) *

Yes, I have watched the video

NOTE: When on site, please ensure you follow Company policy in respect of Covid-19, to include our on-site standard procedures regarding infection control (e.g., hand washing/hand sanitising, general coughing/sneezing etiquette, etc.). Information supplied in this questionnaire by our employees may be shared with our direct business contacts where you are attending their site for the provision of our services, or where they come into contact with you whilst you are performing your work duties. I confirm that the above information is accurate to the best of my knowledge. I consent to having this data retained by County Roscommon Disability Support Group CLG to fully company with governmental and HSE guidelines. *

I CONFIRM