Drogheda Grammar School – Student Personal Health Declaration

This Form ONLY to be completed three days before starting back to school.

Do not complete before August 24th 

Should you answer “Yes” to any of the below – Your son/daughter should not attend school and inform us immediately

 

Student Name (required)

Year/Form of your son/daughter(required)

Has your son/daughter been in close contact (<2m for 15minutes or more) with anyone who is confirmed to have had COVID-19 virus in the last 14 days? (required)

YesNo

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

YesNo

Does your son/daughter live in the same household with someone who has symptoms of COVID-19 who has been in isolation within the last 14 days? (required)

YesNo

Has your son/daughter been advised by a doctor to self-isolate at this time? (required)

YesNo

Is your son/daughter suffering now, or have you suffered any the following symptoms in the past 14 days? (required)

Cough: YesNo
Breathing difficulties: YesNo
Fever/ High temperature: YesNo
Sore Throat: YesNo
Runny Nose: YesNo
Flu Like Symptoms: YesNo
Rash: YesNo
Loss Of Smell/Taste: YesNo


Has your son/daughter been advised by a doctor to cocoon? (required)

YesNo

Has your son/daughter returned to Ireland from another country within the last 14 days? (required)

YesNo

I have read and agree with the Drogheda Grammar School COVID-19 Response plan and amendment to the Code of Behaviour Policy in line with school safety control measures (required)

Yes

My son/daughter has read and agrees with the Drogheda Grammar School COVID-19 Response plan and amendment to the Code of Behaviour Policy in line with school safety control measures (required)

Yes


Declaration (required):


Parent / Guardian Name (required)

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