Cobh Pirates RFC - PRE-RUGBY PERSONAL ASSESSMENT DECLARATION
This form must be completed and submitted to your club/school before each and every rugby activity (e.g. training or match). Should you answer YES to any of these questions, you should NOT attend your club.
* Required
Please input the date you will be attending the Paddocks for training, match or a Club event.
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1. 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
2. Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?
*
Yes
No
3. Have you been advised by a doctor to self-isolate at this time?
*
Yes
No
4. Have you been advised by a doctor to cocoon or shield at this time?
*
Yes
No
5. 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
6. 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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