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*

Country

What is your Arrival Date in Ireland*

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

Comments

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3. Student Health Questionnaire