Covid 19 - Travel Risk Questionnaire

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Due to the increased cases of the Covid-19 virus within the republic of Ireland we continue to review employees who have or are planning to travel out of the country. This information is to support risk reviews for the safety of employees and to reduce the risk of spreading / contracting the Covid-19 virus.

We would like you to complete this brief questionnaire so we can better risk assess your recent or planned travel.

Employee Name *

Employee Pin Number *

Travel Dates *

Destination of travel (Include all locations visited during your travel period) *

Is the area a Covid-19 affected area? *

Yes

Have you taken the advised preventitive measures issued by the HSE? *

Yes

Risk of having contracted the virus during your travel? *

Low

High

N/A

Do you currently have flu like symptoms? *

Yes

Have you been advised to self isolate by the HSE or a medical practitioner? *

Yes

Do you have any further feedback or information to help us better conduct a risk review? *

Declaration - I confirm I have provided the above information to the best of my knoweldge and understand that travel to an affected area may increase the risk of contracting / spreading the Covid-19 virus which also may impact my roster upon return. *

I acknowledge and accept

Required

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