Self-Declaration – O'Flynn Group

Company

This field is for validation purposes and should be left unchanged.

All persons attending to an OFG premises are required to complete the following questionnaire / self-declaration and are required to comply with the Company Visitor policy and Meeting policy (as displayed in Reception and copy available by request). Thank you for co-operation in this regard by completing the form in full.

OFG may be required to share this information with the HSE in order to assist with contact tracing. This data is being collected in accordance with Government guidelines and will only be used for the purpose of COVID-19 contact tracing and for no other purpose. It will be retained for no longer than 3 months.
If you do not agree to providing your information, admission to the Company premises will not be granted. This is solely for the purposes of protecting the health and saftety of our Employees.

Your Name*

Company*

Contact Number*

Company Representative you have contact with*

Names of other Team members you are checking in.*

Just enter your name if just you. Please put each name on a new line

Reason for Attendance*

Site Location*

If you answer Yes to any of the below, you are strongly advised to follow the medical advice you receive or seek medical advice before returning to work (HSE Live number on 1850 24 1850)

1. Have you or any of your team been in close contact with a confirmed / suspected case of COVID-19 in the past 14 days (i.e. less than 2m for more than 15 minutes accumulative in 1 day)?*

Yes

No

2. Have you or any of your team been notified that you are a close contact of a confirmed or suspected case of COVID-19?*

Yes

No

3. Are you or any of your team awaiting the results of a COVID-19 test?*

Yes

No

4. Have you or any of your team been diagnosed with confirmed / suspected COVID-19 infection within the past 14 days?*

Yes

No

5. Do you or any of your team have any of following typical COVID-19 symptoms: fever, high temperature, cough, difficulty breathing, sore throat, runny nose or flu-like symptoms, loss or change of taste or smell in the past 14 days?*

Yes

No

6. Have you or any of your team been advised by a doctor to cocoon at this time?*

Yes

No

7. Have you or any of your team been advised to self-isolate at this time?*

Yes

No

8. Have you or any of your team been advised to restrict your / their movements at this time?*

Yes

No

9. Have you or any of the team returned to the island of Ireland from another country within the last 14 days?*

Yes

No

Please enter the names of those that answered YES to the above questions*

Because you or a team member has answered Yes to one or more of the questions above please notify the foreman before attending site

Declaration: I confirm that I have completed and responded to the above questionnaire on my current condition as of the below date.

I agree that the Company can hold this information for three months in order to assist with contact tracing, if required

I will advise the Company if my situation changes:

Confirm*

Please tick to confirm the declaration above

Dated:*