Senior Health Questionnaire

CORK HARLEQUINS HEALTH QUESTIONNAIRE FORM FOR SENIOR CLUB MEMBERS RETURNING TO TRAINING

This document should be completed and returned to the Club Covid-19 Officer (CVO) prior to a player’s first training session.

Player Name:                                                                                     Date of Return to Hockey:

Section/Age Group:                                                                        Training Time:

  1. Do you believe you may currently have COVID-19? YES ____ NO ____
  2. Have you had any of the following symptoms of COVID-19 in the past 14 days?
  • High temperature (over 37.5°C) YES _____ NO _____
  • Loss of sense of smell and/or taste YES _____ NO _____
  • New continuous cough YES _____ NO _____
  • New unexplained shortness of breath YES _____ NO _____

If you have answered YES to any of these questions above, you should stay at home and contact your GP by phone for further advice. If you have answered NO to all the above questions, you may train or play with your team on the date specified above. Please note that you are not to attend training or a match if you have been identified by the HSE as a contact for a person with Covid-19 and to follow the HSE advice on restriction of movement. If you have been outside Ireland you are not permitted to attend training or a match within a period of 14 days of your return. Please note that you will be required to confirm your health status before attending every training session/match.

Please sign this form to confirm that the details above are true to the best of your knowledge and confirm that you understand the risks involved in participation, are participating on a voluntary basis and that you may opt-out at any time.

Declaration: I agree to inform the club CVO should I develop any symptoms of COVID-19 and will not participate in club activity until I have medical clearance to do so.

Signed:* _____________________________________________________________________

 *(For underage players, this document should be signed by a Parent or Guardian)

Please provide your contact details in the event contact tracing is required:

Phone:                                                                                  Email:

Home Address:

Please follow all Hockey Ireland Return to Play Protocol when travelling to and from the ground and when partaking in training sessions.

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