NUIGMC COVID-19 SCREENING QUESTIONNAIRE
This document should be RETURNED TO THE CLUB COVID-19 OFFICER (CVO) PRIOR TO THE CLUB’S FIRST TRAINING SESSION. We recommend that this would be completed electronically and emailed (to avoid additional handling) to the CVO no more than two hours prior to the start of their first session.
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Email *
Name *
For the safety of our climbing community, only vaccined members are allowed into the climbing area until futher notice. You might be asked to show your vaccination passport to the COVID officer in charge. *
Required
Please answer either yes or no to each of these questions *
No
Have you been in contact with someone who has visited an affected region in the past 14 days?
Have you been in contact or around someone with symptoms of COVID-19 in the last 14 days?
Are any members of your household self-isolating?
Are you suffering from any flu-like symptoms or symptoms of COVID-19? (High temperature – over 37.5°C; Loss of smell and/or taste; New unexplained shortness of breath; New continuous cough)
Have you consulted a Doctor or other Medical Practitioner within the last 14 days due to the above-mentioned symptoms?
Do you believe you may currently have COVID-19?
Do you fall in a high-risk health category as per HSE guidelines?
If you have answered “YES” to any of the questions above or have indicated to your COVID-19 Officer or Coach that you may have symptoms of COVID-19, you should NOT attend training and stay at home. You are prohibited from entering or using University grounds / facilities and advised to seek professional medical help/assistance through the appropriate means as directed by the HSE and/or University guidelines. Please sign this form to confirm that the details above are true to the best of your knowledge and confirm that you understand the risks involved in participation, are participating on a voluntary basis and that you may opt-out at any time. *
Required
DECLARATION: *
Required
DECLARATION *
Required
Please provide your contact details in the event contact tracing is required:
Phone number *
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