Portmarnocks - Self Screening Form

Self Screening Form
You will be aware of the ongoing outbreak of COVID-19, also known as Coronavirus. Swim Ireland are adhering to guidance from the Health Protection Surveillance Centre in containing the virus and ensuring a safe environment for athletes and staff.

As one of our measures, we are seeking to identify any potential cases at the earliest opportunity to avoid any contacts/spread. The research to date for this novel virus suggests that transmission appears to be during symptomatic phase, and as such, identifying those with symptoms and isolating them should reduce risk significantly.

In addition, it complies with our general illness rule which is to avoid contacts in the club when ill. Please answer the following questions (YES / NO) prior to travelling to any club-based activity and submit to the club as per their instructions.

This process must be completed for each and every activity with your club that you intend to attend.
username
Name*
Date

DayMonthYear
Date
Squad*
Declaration Statement: I have no reason to believe that the above named child has infectious disease and I have followed all medical and Public Health advice (including Public Health advice in respect of international travel) with respect to the exclusion of my child from swimming activities.*

The above statement is trueThe above statement is not true
Have you been in contact with a case of COVID-19 (>15 minutes face to face contact)?*

YesNo
Tick if you have any of the symptoms below in the last 48 hours?

CoughFeverFeeling short of breathExcessive fatigue/tiredness out of proportion to normal)Sore throatHeadacheGeneral aches and pain (out of proportion to normal)Loss of taste or smellGastrointestinal issues (e.g. Diarrhoea, Nausea, etc.)
Have you been contacted by a member of Public Health about a recent case of COVID-19?*

YesNo
The answer to some of the above questions above was YES, please notify the Lead COVID-19 Officer by phone. You should not leave home and you should not travel to the pool. We recommend you contact your GP for advice
The answers to all questions are NO, you can attend training with your club
Athlete/ Staff Signature:*

Clear
Parent/Carer Signature (if U18):

Clear
Source for form : https://www.swimireland.ie/membership/covid-19-return-to-water/covid-19-faqs
Should be Empty: