Cobh Pirates RFC - Return to Play - Personal Assessment Declaration
Should you answer YES to any of the below questions you should NOT attend your club and before you return you should follow appropriate medical advice and guidelines.
Please input the date you will be attending the Paddocks for training or a Club event. *
MM
/
DD
/
YYYY
Have you been in close contact (<2m for 15minutes or more) with anyone who is confirmed to have had COVID-19 virus in the last 14 days? *
Have you been in close contact (<2m for 15minutes or more) with anyone who is suspected of having COVID-19 virus in the last 14 days? *
Do you live in the same household with someone who has symptoms of COVID-19 who has been in isolation within the last 14 days? *
Have you been advised by a doctor to self-isolate at this time? *
Are you suffering now, or have you suffered any the following symptoms in the past 14 days? *
Yes
No
Cough
Breathing Difficulties
Fever / High Temperature
Sore Throat
Runny Nose
Flu Like Symptoms
Rash
Loss of Smell / Taste
Have you been advised by a doctor to cocoon? *
Have you returned to Ireland from another country within the last 14 days? *
If yes to travel outside Ireland, where did you visit?
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy