Belmayne RTS Form
In the interests of the safety of everyone in BETNS, their families and the community, BETNS ask that you complete the following questionnaire / declaration on behalf of each of your children, currently attending Belmayne ETNS, prior to returning to school after absence for any reason.

Please complete a separate form for each of your children.

Your co-operation and support are appreciated. You are requested not to allow your child to return to the school, until you receive medical advice, if you answer ‘YES’ to any of the questions from 1 - 10. If you answer 'Yes', to any of the questions from 1 - 10 below, please seek medical advice before allowing your child to return to school. If you have already done so, please still answer 'yes' and you can provide further clairty in the comment box towards the end of this form. Upon receipt of medical advice, please contact the school Principal if required and outline details in the comment box towards the end of this form. The school may contact you for more details if we are unclear regarding symptoms and any advice given.

Please ensure that you answer all questions accurately. For example, the question regarding temperature, cough and runny nose etc. If your child did have a sore throat and runny nose, please answer yes to this question. You can explain in the comment box provided, towards the end of the form, the specific symptoms your child had and it is here you can clarify that your child did not and does not have a temperature etc.

Please read the below document (Isolation quick guide for parents and guardians of children older than 3 months and up to 13 years of age) for further clarity.
https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/educationguidance/Isolation%20quick%20guide%20under%2013s.pdf

You will need to fill out this form any time that your child is absent from school.
Email *
Child's Name (Reminder: please complete a separate form for each of your children attending BETNS) *
Child's Class & Class Teacher (Reminder: please complete a separate form for each of your children attending BETNS) *
Are you, your child, in the above identified class, or any member of your household awaiting the results of a COVID-19 test? *
In the past 14 days, have you or your child, in the above identified class, been in contact with a person who is a confirmed or suspected case of COVID-19? *
Does your child, in the above identified class, 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 or your child, in the above identified class, been advised by the HSE that you are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days? *
Have you or your child, in the above identified class, been advised by a doctor to self-isolate at this time? *
Have you or your child, in the above identified class, been advised by a doctor to cocoon at this time? *
Have you or your child, in the above identified class, 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 school. *
Have you or your child, in the above identified class, been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? *
Has your child, in the above identified class, travelled in the past 10 days? *
In the group that your child travelled with were there any unvaccinated adults? *
If you answered 'yes' to the above question, did your child quarantine after travelling with unvaccinated adults? *
In an instance whereby your child has been absent from school for any of the above reasons (ie. had symptoms of COVID-19, was confirmed to have COVID-19, was a close contact of someone confirmed to have COVID-19 etc.) has your child now been medically advised that they are fit to return to school? Please select 'N/A' if this does not apply. *
Any further comments to provide clarity: *
I confirm, to the best of my knowledge that I and my child, in the above-identified class, have no symptoms of COVID-19, are not self-isolating or awaiting results of a COVID-19 test and have followed any COVID-19 guidance, including guidance related to travel. I also agree that I will notify the school immediately of any changes in my/my child's condition. I have no reason to believe that my child has an infectious disease and I have followed all medical and public health guidance with respect to the exclusion of my child from educational facilities.
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.
Please sign below by typing your (parent/guardian) name. *
A copy of your responses will be emailed to the address you provided.
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