Title Page

  • Date

  • Name

  • Name of School

  • Name of Principal

  • This questionnaire must be completed by staff everyday to return to work.
    If the answer is Yes to any of the below questions, you are advised to seek medical advice before returning to work.

  • 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?

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

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

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

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

  • 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.

Sign Off

  • I confirm, to the best of my knowledge that I have no symptoms of COVID-19, am not self-isolating or awaiting results of a COVID-19 test. Please note: The organisation is collecting this sensitive personal data for the purposes of maintaining safety within the workplace in light of the 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.

  • Name and Signature

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.