Self Assessment Form – COVID-19

Self Assessment Form - COVID-19
Are you currently diagnosed with or believe you may have COVID-19? *
Have you had any of these symptoms of COVID-19 in the past 14 days (see - please tick as appropriate *
Have you been in contact with a COVID-19 confirmed or suspect case in the previous 14 days? *
Have you visited or stayed in a closed environment with anyone with COVID-19 in the past 14 days? *
Have you traveled together with COVID-19 patient in any kind of conveyance in the past 14 days? *
Have you arrived in Ireland from another country in the last 14 days – this includes Irish citizens travelling home? *