Title Page
-
Conducted on
-
Prepared by
-
Location
FRM-008 Covid-19 Declaration
-
The safety and wellbeing of our team is essential to us. Due to current government controls to limit the spread of Covid-19 and, to help us reduce the risk to your colleagues and others. Prior to returning to work we ask that you honestly complete this declarationD
-
Contractor or Company Name:
-
Name of site:
-
Print Name
-
I Confirm the following:
-
Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness, flu like symptoms or loss or change to your sense of smell or taste now or in the past 14 days?
-
You have answered YES to the above, you must contact your Supervisor/ Manager (phone or email ONLY) to discuss your return to work. Record details / findings in the text box.
-
Have you been diagnosed with confirmed COVID-19 infection in the last 14 days?
-
You have answered YES to the above, you must contact your Supervisor/ Manager (phone or email ONLY) to discuss your return to work. Record details / findings in the text box.
-
Are you a close contact of a person who is a confirmed case or do you live with someone who has or had symptoms of COVID-19, in the past 14 days?
-
You have answered YES to the above, you must contact your Supervisor/ Manager (phone or email ONLY) to discuss your return to work. Record details / findings in the text box.
-
Have you been advised by a doctor or the HSE to self-isolate at this time?
-
You have answered YES to the above, you must contact your Supervisor/ Manager (phone or email ONLY) to discuss your return to work. Record details / findings in the text box.
-
Have you been advised by a doctor or the HSE to restrict your movements at this time?
-
You have answered YES to the above, you must contact your Supervisor/ Manager (phone or email ONLY) to discuss your return to work. Record details / findings in the text box.
-
Have you been advised by a doctor or the HSE to cocoon at this time?
-
You have answered YES to the above, you must contact your Supervisor/ Manager (phone or email ONLY) to discuss your return to work. Record details / findings in the text box.
-
Have you entered Ireland from a red, orange, or grey region in the last 14 days? ** (EU ‘traffic lights’ applies only to countries in the EU / EEA + UK).
-
You have answered YES to the above, you must contact your Supervisor/ Manager (phone or email ONLY) to discuss your return to work. Record details / findings in the text box.
-
Would you like to provide details 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?
-
You have answered YES to the above, you must contact your Supervisor/ Manager (phone or email ONLY) to discuss your return to work. Record findings in the text box.
You will need to self-isolate if:
-
1. You have COVID-19 symptoms or
2. You have a positive test result
You will need to self-isolate for at least 5 days after any fever and for at least 10 days after developing symptoms.
You will need to restrict your movements for 14 days if you:
-
1. Are a close contact of a confirmed case of COVID-19 (i.e. less than 2 metres for more than 15 minutes altogether in 1 day)
2. Live with someone who has symptoms of COVID-19, but you feel well
3. Arrive into Ireland from a region that is not on the COVID-19 green list.
You should restrict your movements for 14 days even if you receive a negative COVID-19 test result.
Do not go to work unless you work on your own and can completely avoid other people.
(If you do not have symptoms and you are an essential worker, speak to your employer.)
HSE AT RISK GROUPS :
-
These people need to take extra care to protect themselves from coronavirus. This is on top of the advice that everyone needs to follow to protect themselves and others from coronavirus.
If you are in one of the following high-risk groups, please inform your supervisor or manager immediately:
• are over 60
• have a long-term medical condition - for example, heart disease, lung disease, diabetes, cancer, cerebrovascular disease, renal disease, liver disease or high blood pressure
• have a weak immune system (immunosuppressed)
• have a medical condition that can affect your breathing
• are residents of nursing homes and other long-stay settings
• are in specialist disability care and are over 50 years of age or have an underlying health problem
What people in at-risk groups should do?
• Please seek medical guidance in relation to your return to work.
• Review with your employer if additional controls can be implemented to reduce the risk to an acceptable level.
• Complete an individual risk assessment confirming additional controls implemented. -
Are you within the “At Risk” groups listed above: YES (please tick if applicable)
-
Have you previously completed an individual covid-19 risk assessment
-
Please contact HR or Safety department (phone or email ONLY) to discuss any additional controls.
-
** This period of restricted movement can end if you receive a negative/’not detected’ result of a (Polymerase Chain Reaction) PCR test that has been taken a minimum of five days after your arrival in Ireland. If you arrive from a region that is rated orange, you can have the PCR test taken during the 3 days before departure and you do not have to restrict your movements if you can show a negative test result (EU ‘traffic lights’ applies to countries in the EU / EEA + UK). Record your test result details in the comment section and provide a copy of the report to the HR dept prior to returning to work
Completion & sign off
-
By signing this form, I declare all the information provided is true and accurate
-
Signature
-
Complete and forward this report to the HR or Safety department
