Pre return to training – Old Belvedere RFC

Pre-Return To Rugby Personal Assessment Declaration

Should you answer YES to any of the below questions you should NOT attend your club and before you return you should follow appropriate medical advice and guidelines.

1. Have you been in close contact (<2m for 15minutes or more) with anyone who is confirmed to COVID-19 virus in the last 14 days?*

Yes

2. Have you been in close contact (<2m for 15minutes or more) with anyone who is suspected of having COVID-19 virus in the last 14 days?*

Yes

3A. Do you live in the same household with someone who has symptoms of COVID-19 who has been in isolation within the last 14 days?*

Yes

3B. Have you been advised by a doctor to self-isolate at this time?*

Yes

5. Have you been advised by a doctor to cocoon?*

Yes

6. Have you returned to Ireland from another country within the last 14 days?*

Yes

If “YES”, where?

I confirm that I have not travelled from another country in the past 14 days , that I have not been in close contact with anyone who has been outside of the country in the past 14 days, that I have not been in close contact with anyone who is in self-isolation in relation to COVID-19 in the past 14 days, that I am not suffering from any COVID-19 symptoms nor do I believe for any reason that I have contracted the virus. I commit to advising management and excluding myself if this situation changes, (i.e. if at a point in the future, I would answer “yes” to any of the above questions).

Name*

First

Last

Date

Are you human?*

This field should be left blank