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Student Health Questionnaire
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Student Health Questionnaire
Student Health Questionnaire
David Horner
2020-08-15T23:21:44+01:00
3. Student Health Questionnaire
To help prevent the spread of Covid-19 in the school, every student must complete and sign this form before commencing or returning to classes (after an unscheduled break). On receipt of your form, we may contact you and ask you not to join classes immediately and/or discuss a suitable future date for your commencement. This form must be completed at least three days in advance of your class starting date. You will be required to resubmit this form after each and every unscheduled break of 1 week or more.
Student Name
*
First
Last
Email Address
*
Mobile Telephone (for WhatsApp Contact)
*
Are You Already Living in Ireland (and do not need to restrict movements because of travel) ?
*
Irish Government is Operating the EU Traffic Light System for international travel. To find out if you are reqested to restrict your movements after arrival
Click Here For Travel Advice
YES - I am living in Ireland and I do not need to restrict my movements for 14 days
NO
Which Country Will You Be Arriving From
*
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
What is your Arrival Date in Ireland
*
Date Format: MM slash DD slash YYYY
Did you reserve accommodation in Dublin through Horner School ?
*
Yes
NO
Are you sharing your bedroom with another person ?
*
No, I have my own bedroom
Yes, I am sharing my bedroom but with only one other person
Yes, I am sharing my bedroom with more than 1 other person
Please tell us how may persons you are sharing the bedroom with ?
What is your accommodation address in Dublin ?
Street Address
Address Line 2
City
1. Do you have any symptoms of Covid-19 such as cough, fever, high temperature, loss of sense of taste or smell, breathlessness or flu-like symptoms, now or in the last 14 days?
*
Yes
No
2. Have you been diagnosed with confirmed or suspected Covid-19 infection in the last 14 days?
*
Yes
No
3. Have you been in close contact with a person who is a confirmed or suspected case of Covid-19 in the past 14 days ?
*
Yes
No
4. Have you been advised by a doctor to self-isolate at this time?
*
Yes
No
5. Have you been advised by a doctor that you are in a vulnerable or high risk group?
*
Yes
No
COVID-19 is often more severe in people who are older than 60 years or who have health conditions like lung or heart disease, diabetes or conditions that affect their immune system.
6. Please provide details below of any other circumstances relating to Covid-19, not included in the above, which may need to be considered to allow your safe return to school..
If your situation changes after you complete and submit this form, please inform us immediately.
Please tick to confirm.
*
I confirm that I have read the Covid-19 Pre-Arrival Information Page and the information I have provided, is to the best of my knowledge correct and can be used for the purposes of contact tracing.
1. I will follow the Covid-19 protection measures to the best of my ability. 2. If I have symptoms of Covid-19 infection, I will not come to school. I will inform the school and I will self-isolate for the recommended quarantine period. 3. In the unlikely event that I am unable to attend lessons, I understand I cannot claim a refund. In the event of a lock-down request from government or a whole class quarantine request from public health authorities, I accept that classes will be moved online. 4. I understand that I should not stay in accommodation that is overcrowded, unsafe of unhygienic.
Date
Date Format: DD slash MM slash YYYY
Comments
This field is for validation purposes and should be left unchanged.