COVID-19 Player Self-Assessment Form

To ensure the Health & Safety of all people interacting with our club, all visitors must complete this declaration form prior to entering our site. If you indicate to us that you have symptoms of COVID-19 or you have been abroad in the last 14 days, with the exception of travel between Northern Ireland and Republic of Ireland, you should not attend the club’s training facility. Where this is the case, you are prohibited from entering or using the club and advised to seek professional medical help/assistance.

Please fill out the below assessment form as soon as possible.

This information will be kept strictly confidential and only used by the Club Covid Offers as part of our safe Return to Training protocol.

THE ONUS IS ON THE PLAYER / PARENT TO INFORM THE CLUB IMMEDIATELY IF THERE IS ANY CHANGE TO THE ANSWERS GIVEN BELOW ONCE THIS ASSESSMENT IS COMPLETED.

Question Title

* 1. Please enter players contact details below (If you are a parent completing it on behalf of your child you should enter your child's name followed by your name in brackets and include your contact details. The questions that follow are obviously in relation to your child i.e. the player)

Question Title

* 2. Do you currently have, or have you been diagnosed as having COVID-19 in the last 14 days?

Question Title

* 3. Are you awaiting results of a test relevant to COVID-19?

Question Title

* 4. Have you traveled abroad in the last 14 days?

Question Title

* 5. If yes, please state where.

Question Title

* 6. Have you displayed any symptoms of COVID-19 in the last 14 days, namely fever, high temperature, persistent coughing, breathing difficulties / shortness of breath, and / or loss of taste or smell?

Question Title

* 7. If yes, which symptom(s) have you displayed

Question Title

* 8. Do you live in the same household as someone, or have been in close contact with someone (i.e. less than 2 metres for more than 15 minutes accumulative in 1 day) who has displayed symptoms of COVID-19 in the last 14 days or who has a confirmed case of COVID-19?

Question Title

* 9. If you answered Yes to any of the above questions, have you contacted a doctor or other medical practitioner? If Yes, then please follow the medical advice that you are receiving or, failing that, seek medical advice.

Question Title

* 10. Have you been advised by a doctor to cocoon or self-isolate at this time?

Question Title

* 11. 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 for your safe return to training

Question Title

* 12. I confirm that the above information is correct and that I consent to The Hills Cricket Club contacting me with further information in relation to the clubs Return to Training Protocols.

I understand that my details will be kept on file by the club Covid Officer for the purpose of contact tracing as per HSE / Cricket Ireland guidelines and I give my consent to this.

0 of 12 answered
 

T