Coronavirus COVID-19 Screening Questionnaire Coronavirus COVID-19 Screening Questionnaire PDFFeel 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. All data entered into our forms is automatically deleted from our server daily. domain Company Name Questionnaire Is For info Project/Site Name domain Your Employer (Organisation) date_range 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?*YesNoHave you been in close contact with anyone who are a suspected or confirmed with having the COVID-19 virus?*YesNoDo you live in the same household with someone who has symptoms of COVID-19 who has been in isolation within the last 14 days?*YesNoAre you displaying any of the following symptoms (cough, high temperature, shortness of breath, difficulty breathing) within the last 14 days?*YesNoAre you returning to work after isolation following symptoms of COVID-19 please answer the below:*YesNoHave you been free of a temperature of 38.5 + ◦C for the last 5 days?*YesNoHas it been 14 days since your first symptom appeared?*YesNoDo you have any symptoms of Covid-19 now?*YesNoDo you use public transport to travel to work?*YesNoDo you share a vehicle with other persons to travel to work other than persons you share accommodation with?*YesNoYour 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 copyConsent* ConsentI hereby confirm that the information is correct as at the date below and will undertake to inform my Employer should the information above change. perm_identity Your Name Signature*PDF Preview PhoneThis field is for validation purposes and should be left unchanged.