COVID-19 VISITORS FORM

COVID-19 VISITORS SELF DECLARATION
Document No:PD-QR 10.3 | ReV. No:00 | ReV. Date: 28/05/2020
Your Name:*
Company:*
Appointment Date & Time*

MonthDayYear
DateHourMinutesAM/PM Option
Purpose of Visit:
P+ D Contact Person:*
To ensure the Health and Safety of all P+D employees and community, all visitors and Contractors must complete this declaration form prior to entering our Premises. Where possible please return the completed form and forward to info@pdvisual.ie and your contact person at least 24 hours prior to your visit.

If you have symptoms of COVID-19 you should not be at work or have been abroad in the last 14 days with the exception of green list countries. Where this is the case, you are prohibited from entering the site and advised to seek professional medical assistance
QUESTION
1. Have you currently or in the last 14 days exhibited any of the symptoms associated with Covid-19 which include: Cough; Fever or High Temperature < 38°; Breathlessness or Flu-like symptoms such as Runny Nose or Sever Muscle Ache?*
2. Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?*
3. Have you been in close contact with anyone who has been diagnosed with a confirmed case of COVID-19 in the last 14 days (i.e. Less than 2 meters or more for three none that 15 minutes accumulative in 1 day?*
4. Have you been advised by a Doctor to self-Isolate or cocoon at this time?*
5. Has anyone in your household been advised by a medical professional to self-isolate or Cocoon? *
6. Have you travelled outside Ireland excluding Northern Ireland over the past 14 days (Current requirement to self-Isolate for 14 days after international travel?*
NOTE: When on P+D premises, please adhere to the guidelines set out by www.gov.ie: www.hse.ie and www.hsa.ie Regarding infection control, i.e. Social distancing by keeping a 2-metre space between you and other people, hand washing hand sanitising and general coughing/sneezing etiquette.
Self Declaration
Print Name:*
Signed:

Clear
Date

MonthDayYear
Date
NOTE: The data collected is required in order that we can ensure the health and well-being of our community, allowing us to contact and trace visitors in case of a Covid-19 outbreak. The data collected will be processed by P+D in its current format and will not be passed on to third parties unless required legally to do so. The data will be held securely for a period of 1 month from the time of the visit by P+D after which it will be securely destroyed.
Should be Empty:

COVID-19 VISITORS SELF DECLARATION

QUESTION

Self Declaration