Covid Safety Checklist
Interface Inagh
Name *
Email *
Address *
Phone number *
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? *
Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. lessthan 2m for more than 15 minutes accumulative in 1 day)? *
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? *
I confirm that I have responded to the questions above truthfully based on my current condition. I also commit to advising the Executive Director at Interface if this situation changes and I will exclude myself from entering the workspace should I develop COVID-19 Symptoms and seek GP advice while I self-isolate at home. *
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