The Self Declaration Form COVID 19 was developed in response to the need for organizations in Ireland to implement effective COVID-19 screening measures while complying with legal and regulatory requirements. This document is typically used before individuals enter workplace premises or attend events, serving as a risk management tool and supporting contact tracing efforts. The form aligns with the Irish government's Work Safely Protocol and incorporates requirements from the Health Act 1947 (Section 31A - Temporary Restrictions) (COVID-19) Regulations 2020, while ensuring compliance with GDPR and Irish data protection laws. It is designed to collect relevant health information, travel history, and close contact details in a manner that balances public health requirements with individual privacy rights.
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1. Personal Information: Basic identification details including name, contact information, and role/purpose of visit
2. Health Status Declaration: Current health status, presence of COVID-19 symptoms, and recent COVID-19 test results if applicable
3. Close Contact Declaration: Declaration regarding close contact with confirmed COVID-19 cases in the specified timeframe
4. Travel Declaration: Information about recent travel history, particularly to areas with high COVID-19 rates
5. Acknowledgment: Confirmation that all information provided is true and understanding of obligations to report any changes
6. Data Protection Notice: Information about how personal data will be processed, stored, and protected in compliance with GDPR
7. Signature and Date: Space for signature (electronic or physical) and date of completion
1. Vaccination Status: Optional section for declaring COVID-19 vaccination status when relevant for specific workplace requirements
2. Temperature Check Consent: Optional section for workplaces that implement temperature screening protocols
3. Specific Workplace Protocols: Additional declarations related to specific workplace safety measures or industry requirements
4. Return to Work Declaration: Specific section for employees returning after illness or isolation period
1. Appendix A - Symptom Checklist: Detailed list of COVID-19 symptoms for reference
2. Appendix B - Close Contact Definition: Detailed explanation of what constitutes a close contact as per current HSE guidelines
3. Appendix C - Privacy Notice: Detailed information about data protection rights and procedures
4. Appendix D - Relevant Contact Information: List of important contact numbers and procedures for reporting COVID-19 related concerns
Relevant legal definitions
COVID-19
Close Contact
Self-Isolation
Restricted Movement
HSE
Symptoms
Contact Tracing
Personal Data
Data Controller
Workplace
Premises
Designated Person
COVID-19 Response Plan
Risk Assessment
PCR Test
Antigen Test
Isolation Period
Essential Travel
Physical Distancing
Face Covering
Vaccination Status
HSA
Work Safely Protocol
Vulnerable Person
Close Contact
Self-Isolation
Restricted Movement
HSE
Symptoms
Contact Tracing
Personal Data
Data Controller
Workplace
Premises
Designated Person
COVID-19 Response Plan
Risk Assessment
PCR Test
Antigen Test
Isolation Period
Essential Travel
Physical Distancing
Face Covering
Vaccination Status
HSA
Work Safely Protocol
Vulnerable Person
Clauses
Personal Information
Health Declaration
Data Protection
Privacy
Consent
Travel History
Close Contact Declaration
Symptom Declaration
Compliance
Acknowledgment
Certification
Information Accuracy
Duty to Inform
Vaccination Status
Testing Declaration
Risk Acknowledgment
Workplace Safety
Declaration of Understanding
GDPR Compliance
Health and Safety
Health Declaration
Data Protection
Privacy
Consent
Travel History
Close Contact Declaration
Symptom Declaration
Compliance
Acknowledgment
Certification
Information Accuracy
Duty to Inform
Vaccination Status
Testing Declaration
Risk Acknowledgment
Workplace Safety
Declaration of Understanding
GDPR Compliance
Health and Safety
Relevant Industries
Healthcare
Education
Retail
Manufacturing
Construction
Professional Services
Hospitality
Transportation
Public Sector
Financial Services
Technology
Entertainment and Events
Relevant Teams
Human Resources
Health and Safety
Facilities Management
Operations
Security
Administration
Risk Management
Occupational Health
Legal
Compliance
Relevant Roles
HR Manager
Health and Safety Officer
Facility Manager
COVID-19 Compliance Officer
Operations Manager
Office Manager
Reception Staff
Security Personnel
Department Supervisor
Site Manager
Occupational Health Nurse
Risk Management Officer
Employee Relations Manager
Administrative Assistant
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