COVID-19 SCREENING QUESTIONNAIRE

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Coronavirus

COVID-19

Screening Questionnaire

Coronavirus COVID-19 Screening Questionnaire PDF

Feel free to use this Coronavirus COVID-19 Screening Questionnaire form, Click on the image to view an example PDF file that the form will create.
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Company Name Questionnaire Is For
Project/Site Name
Your Employer (Organisation)
Date
Reason (e.g. commencement of work, meeting etc)*

Reason (e.g. commencement of work, meeting etc)
Have you returned to the island of Ireland from another country within the last 14 days?*
- Yes
- No
Have you been in close contact with anyone who are a suspected or confirmed with having the COVID-19 virus?*
- Yes
- No
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?*
- Yes
- No
Are you displaying any of the following symptoms (cough, high temperature, shortness of breath, difficulty breathing) within the last 14 days?*
- Yes
- No
Are you returning to work after isolation following symptoms of COVID-19 please answer the below:*
- Yes
- No
Have you been free of a temperature of 38.5 + ◦C for the last 5 days?*
- Yes
- No
Has it been 14 days since your first symptom appeared?*
- Yes
- No
Do you have any symptoms of Covid-19 now?*
- Yes
- No
Do you use public transport to travel to work?*
- Yes
- No
Do you share a vehicle with other persons to travel to work other than persons you share accommodation with?*
- Yes
- No
Your Email*

Your Email
Send a copy of this questionnaire*

Send a copy of this questionnaire

Enter an email address of the company you would to send a copy
Consent*
Consent
I hereby confirm that the information is correct as at the date below and will undertake to inform my Employer should the information above change.
Your Name
Signature*
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Name
This field is for validation purposes and should be left unchanged.

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