Student self-declaration

Student Name *

First Name

Last Name

Name of School Principal *

First Name

Last Name

Date of return to school *

MM

DD

YYYY

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

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

Yes

No

Have you been advised by the HSE that you are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days? *

Yes

No

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

Yes

No

Have you been advised by a doctor to cocoon at this time? *

Yes

No

Have you been advised by your doctor that you are in the very high risk group? If yes, please liaise with your doctor and Principal re return to work. *

Yes

No

I confirm, to the best of my knowledge that I have no symptoms of COVID-19, am not self-isolating, awaiting results of a COVID-19 test or 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 ofthe COVID-19 pandemic. The legal basis for collecting this data is based on vital public health interests and maintaining occupational health and will be held securely in line with our retention policy.I commit to advising the schooland not attending the school if this situation changes, (i.e. if a point in the future, I would answer “Yes” to any of the above questions). *

Yes, I confirm.

Student Name as electronic signature *

First Name

Last Name

Parent Name as electronic signature *

First Name

Last Name