Title Page

  • Conducted on

  • Time in

  • Time out

  • Full name

  • Phone number

  • Company

  • Visiting

Questionnaire

  • As the Coronavirus Disease (COVID-19) outbreak continues to evolve, we are conducting a simple daily screening questionnaire in order to reduce any potential risk of exposure to our employees, customers and visitors.

  • NOTE: When on site, please adhere to our on-site standard processes/procedures regarding infection control, i.e. hand washing/hand sanitising and general coughing/sneezing etiquette.

Now or in the last 14 days, please confirm you or a cohabitant or a close family member have not;

  • Visited any countries outside of Ireland excluding Northern Ireland.

  • Had any flu like symptoms/symptoms of COVID-19 (fever, cough, difficulty breathing)

  • Been in contact with or near (less than 2 meters for more than 15 minutes in 1 cumulative<br>day) anyone who is now diagnosed to have COVID-19 (Coronavirus)

  • Been advised by a Doctor to self-isolate or cocoon

  • Been in a hospital, care facility, work environment, which has experienced a known outbreak of COID-19 in the past 14 days.

  • Did you answer ‘ YES ‘ to any of the above questions?

  • PLEASE DO NOT PROCEED INTO THE WORKPLACE AND SELF ISOLATE IMMEDIATELY IN THE PRE DETERMINED SELF ISOLATION ROOM.

Access

  • Access to workplace

  • Access determined by (Name)

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.