Cobh Pirates RFC - PRE-RUGBY PERSONAL ASSESSMENT DECLARATION
This form must be completed and submitted to your club before each and every rugby activity (e.g. training or match). Should you answer YES to any of questions 1-5, you should NOT attend your club. For question 6, the latest government travel advice applies. Before you resume, you should follow appropriate medical advice and guidelines.
* Required
Please input the date you will be attending the Paddocks for training or a Club event.
*
MM
/
DD
/
YYYY
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)
*
Yes
No
Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?
*
Yes
No
Have you been advised by a doctor to self-isolate at this time?
*
Yes
No
Have you been advised by a doctor to cocoon or shield at this time?
*
Yes
No
Are you suffering now, or have you suffered any the following symptoms in the past 14 days?
*
Yes
No
Cough
Fever
High Temperature
Sore Throat
Runny Nose
Breathlessness
Loss of Smell/Taste
New Skin Rash
New Gastrointestinal symptoms
Flu Like Symptoms
Yes
No
Cough
Fever
High Temperature
Sore Throat
Runny Nose
Breathlessness
Loss of Smell/Taste
New Skin Rash
New Gastrointestinal symptoms
Flu Like Symptoms
Have you returned to Ireland from another country within the last 14 days?
*
Yes
No
If yes to travel outside Ireland, where did you visit?
Your answer
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