Covid-19 Questionnaire / Self-Declaration

In the interest of safety of the people of this Club, their families, and the community, you are required to complete the following questionnaire / self-declaration before returning to rowing season and also prior to every training session.

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Have you been in close contact with a confirmed / suspected case of COVID-19 in the past 14 days (i.e. less than 2m for more than 15 minutes accumulative in 1 day)? *YESNO

Have you been advised by a doctor to restrict your movements at this time? *YESNO

Have you returned to the island of Ireland from another country within the last 14 days? *YESNO

If ‘YES’, where?

Do you have any of the following typical COVID-19 symptoms; fever, high temperature, persistent coughing, or breathing difficulties / shortness of breath? *YESNO

Have you been diagnosed with confirmed / suspected COVID-19 infection or been advised, by a doctor to self- isolate within the past 14 days? *YESNO

I confirm that I have responded to the questions above truthfully based on my current condition and I commit to advising LPRC and excluding myself from rowing if this situation changes. (i.e. if a point in the future, I would answer ‘Yes’ to any of the above questions). *

• YES
• NO

Name *

First

Last

Parents Name

Email *

Date *

GDPR: I UNDERSTAND THAT THIS FORM WILL ONLY BE USED FOR THE PURPOSE OF ASSESSING IF I CAN TAKE PART IN CLUB ACTIVITIES AND FOR THE PURPOSES OF CONTACT TRACING. THE FORM WILL BE KEPT FOR A MAXIMUM OF A MONTH BEFORE BEING SECURELY DISPOSED OF.

• YES
• NO

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