Benchspace Workshop Guest / Contact Tracing Form
Please ensure you have masks with you before visiting Benchspace, we would appreciate it if you installed the HSE contact tracing app prior to your visit.

Data is held for contact tracing purposes only and will be deleted regularly in line with GDPR guidelines.
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Full Name *
Contact Number
Email address
Name and Contact number in case of emergency
Do you have any health issues that could  be relevant to activities
1. 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? *
Required
2. Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? *
Required
3. 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. less than 2m for more than 15 minutes accumulative in 1 day)? *
Required
4. Have you been advised by a doctor to self-isolate at this time? *
Required
5. Have you been advised by a doctor to cocoon at this time? *
Required
I will inform hello@benchspacecork.ie if any of the answers to Q. 1 to 5. change. *
Required
If you have answered Yes to any of the above questions you are strongly advised to follow the medical advice you receive or seek medical advice BEFORE visiting Benchspace
6. Are you in a Vulnerable and High Risk group (see Appendix 1 below) ? *
Required
Appendix 1
VERY HIGH RISK GROUPS  (extremely vulnerable)

The list of people in very high risk groups include people who:
- are over 70 years of age - even if you're fit and well
- have had an organ transplant
- are undergoing active chemotherapy for cancer
- are having radical radiotherapy for lung cancer
- have cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment
- are having immunotherapy or other continuing antibody treatments for cancer
- are having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
- have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs
- severe respiratory conditions including cystic fibrosis, severe asthma, pulmonary fibrosis, lung fibrosis, interstitial lung disease and severe COPD
- have a condition that means you have a very high risk of getting infections (such as SCID, homozygous sickle cell)
- are taking medicine that makes you much more likely to get infections (such as high doses of steroids or immunosuppression therapies)
- have a serious heart condition and you're pregnant


HIGH RISK GROUPS


The list of people in high risk groups includes people who:
- are over 60 years of age
- have a learning disability
- have a lung condition that's not severe (such as asthma, COPD, emphysema or bronchitis)
- have heart disease (such as heart failure)
- have high blood pressure (hypertension)
- have diabetes
- have chronic kidney disease
- have liver disease (such as hepatitis)
- have a medical condition that can affect your breathing
- have cancer
- have a weak immune system (immunosuppressed)
- have cerebrovascular disease
- have a condition affecting your brain or nerves (such as Parkinson's disease, motor neurone disease, multiple sclerosis, or cerebral palsy)
- have a problem with your spleen or have had your spleen removed
- have a condition that means you have a high risk of getting infections (such as HIV, lupus or scleroderma)
- are taking medicine that can affect your immune system (such as low doses of steroids)
- have obesity
- 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 TO DO IF YOU IN A VERY HIGH OR HIGH RISK GROUP

Please follow the advice of the HSE and contact your manager to discuss any necessary supports

7. If you answered Yes to Q. 6 are you fit to be in close contact with others? The medical condition should only be discussed with a medical provider (Occupational Health Physician or Nurse and/or GP)
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