COVID-19 Questionnaire

How are you feeling today?*
- I feel well
- I feel unwell
Mark the symptoms have you been experiencing*
- Fever
- Dry Cough
- Tiredness/fatigue
- Aches and pains
- Sore throat
- Diarrhoea
- Conjunctivitis
- Loss of taste or smell
- Difficulty breathing or shortness of breath
- Other
Other – Describe the symptoms*
Diagnosed/ Suspected / Medical Advised
Please read the questions below carefully and answer accordingly.
Have you been in close contact with a person who is a confirmed or suspected case of COVID-19 in the past 14 days?*
(I.E. less than 2 meters for more than 15 minutes in 1 day)
- Yes
- No
Have you been diagnosed with confirmed or suspected covid-19 Infection in the last 14 days?*
- Yes
- No
When did you take your Covid Test?*

Day
Month
Year
Have you been advised by a doctor to self-isolate at this time or have you returned to Ireland from overseas in the last 14 days?*
- Yes
- No

If you have
1. selected that you have COVID-19 symptoms,
2. that you have been advised to isolate, or
3. that you have been in close contact with a suspected or confirmed COVID-19 case or
4. that you have been diagnosed with COVID-19 or have entered Ireland from overseas within in the last 14 days

You SHOULD NOT travel to Ireland/come to the College.
Please follow the medical advice that you may have received. Make contact with the relevant person in your college.

If you have
1. indicated that you are not symptomatic,
2. not self-isolating and
3. have had no close contact with a person who is suspected or a confirmed COVID-19 case,

You CAN TRAVEL/ ATTEND COLLEGE.
Statement*
I have read and agree with the above statement.
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. Further information on people at higher risk from Coronavirus can be accessed here

Diagnosed/ Suspected / Medical Advised