Alexandra Quay, Eirfreeze Building, Bond Road, Dublin Port, D03 X2W0
(01) 855 7007
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Coronavirus Screening Assessment
General Information
Coronavirus Questionaire
Have you had symptoms of Coranavirus within the past 10 days? (Y/N)
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Has any of those you share a house with had symptoms of Coronavirus within the last 14 days? (Y/N)
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Have you been in close contact with anyone who has been tested and confirmed as having Covid-19 within the last 14 days? (Y / N)
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Does anyone you share a house with meet the government definition as being within the “high risk group”. [e.g. Over 70, have underlying health conditions or pregnant?] (Y / N)
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No
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Have you travelled outside Republic of Ireland within the last 14 days to any country, including the UK? (Y / N)
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Have you worked on any non-company site within the last 14 days? (Y / N)
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Are you on any temperature reducing or cough controlling medication? (Y / N)
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Is the individual displaying any signs of a persistent cough? (Y / N)
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No
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Does the individual have any signs of high temperature/ fever? (Insert temperature reading or ‘NO’ if self-declared).
Yes
No
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Do you or any of your household have any underlying health conditions, clinical conditions or conditions of concern (see below)? (Y / N)
Yes
No
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