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.
All data entered into our forms is automatically deleted from our server daily.

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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Phone
This field is for validation purposes and should be left unchanged.

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