COVID Questionnaire | Karen Murphy Speech and Drama

COVID Questionnaire

In the interests of safety of the people at Karen Murphy S. D. & C., their families and the community, Karen asks that you complete the following questionnaire / self-declaration. Your co-operation and support are appreciated. You will be requested to leave or not enter the premises and seek medical advice if you answer ‘YES’ to any of the following Questions.

press Enter

Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness, loss of the sense of smell / taste or flu like symptoms now or in the past 14 days? *

Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? *

Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. less than 2m for more than 15 minutes accumulative in 1 day)? *

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

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 Class.

Name *

First

Last

Date *

Email *

I confirm that I have answered the above questions truthfully and to the best of my knowledge. I will inform Karen if at any-time in the future I answer yes to any of the above questions. Please enter your email, so we can follow up with you.

Name *

First

Last

Website