Covid 19 Site Visitor Questionnaire

Have you travelled outside the REPUBLIC OF IRELAND within the past 14 days? *

Have you been in close contact with anyone who is a suspected or confirmed case of COVID-19? *

How is your health today, are you feeling well or unwell? *

Have you had any of the following in the past 14 days: cough, high temperature/fever, sore throat, runny nose, breathlessness, or flu-like symptoms? *

Have you been diagnosed with COVID-19 in the last 14 days? *

Have you been advised by a doctor to self-isolate at this time? *

Are there any other circumstances relating to COVID19 not on this form that you may need to consider to ensure your safety? These include concerns for an underlying health condition, pregnancy or other. *