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Skibbereen Community School

About us
School Life
Enrolment
Guidance & Counselling
Parent Zone
Contact
VSWare

Staff Return to Work Form

This Return to Work Form must be completed by school staff in advance of returning to the workplace. If the answer is “Yes” to any of the below questions, you are advised to seek medical advice before returning to the workplace.

Name *

First Name

Last Name

Name of School *

Name of School Principal *

First Name

Last Name

Date of return to work (dd/mm/yyyy) *

Do you have symptoms of cough, fever, high temperature (38 degrees C or above), difficulty breathing, loss or change in your sense of smell or taste now or in the past 14 days? *

Yes

Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? *

Yes

Are you awaiting the results of a COVID-19 test? *

Yes

In the past 14 days, have you been in contact with a person who is a confirmed or suspected case of COVID-19? *

Yes

Have you been advised to self-isolate at this time? *

Yes

Have you been advised to restrict your movements at this time? *

Yes

Have you been categorised as "Very High Risk" or "High Risk" by the Occupational Health Service (OHS) *

Yes

Please provide details below of any other circumstances relating to COVID-19, not included in the above, which may need to be considered to allow your safe return to work e.g. returning from travel abroad.

Name as digital signature *

First Name

Last Name

Date (dd/mm/yyyy) *

Please note: The school is collecting this sensitive personal data for the purposes of maintaining safety within the workplace in light of the COVID-19 pandemic. The legal basis for collecting this data is based on vital public health interests and maintaining occupational health and this data will be held securely in line with our retention policy.

Thank you! Your self-declaration has been submitted.

*If your situation changes after you complete and submit this Return to Work Form, please inform your employer.

**Further information on people at very high risk (extremely vulnerable) or high risk from COVID-19 can be found here.

***Details of current arrangements for travel overseas can be found set out here.

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