COVID 19 screening

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COVID 19 Screening Form Ireland

This form must be completed and submitted, BEFORE you can return to class.
If any of the answers below change , it is your responsibility to immediately inform your instructor or the club COVID-19 officer.

Under the General Data Protection Regulation (GDPR) (EU) 2016/679, the ETSDF recognizes its legal duty to protect any information we collect from you. Information contained in this online form are privileged and confidential and intended for the exclusive use of the H&S and wellbeing of their students, instructors and general public. We are committed to ensuring the security and protection of the personal information that we process, and endeavor to provide a compliant and consistent approach to data protection.

* Indicates required field

Person completing this online form *

First

Last

Students Name *

First

Last

Instructors Name *

First

Last

What DoJang do you train in ? *

Telephone number (Parent’s number if under 18) *

Have you visited any countries outside of Ireland excluding Northern Ireland? *

Yes No

Are you suffering any flu like symptoms or symptoms of COVID-19? * *

Yes No Not Sure

Are you experiencing any difficulty in breathing or shortness of breath? *

Yes No

Are you experiencing any fever-like symptoms? *

Yes No

Have you consulted a doctor or other medical practitioners within the last 14 days? *

Yes No

Have been around someone with symptoms of COVID-19 in the last 14 days? *

Yes No

Is a member of your household self-isolating? *

Yes No

Are you in a period of self-isolation under the current HSE guidelines? *

Yes No

Are you in a high-risk health category? *

Yes No

Email *

Reminder if any of these answers change it is your responsibility to inform your instructor or COVID-19 club officer

If you have answered “YES” to any of the questions above or have indicated to us that you have symptoms of COVID-19
you should not attend your club. You are prohibited from entering or using the grounds / facilities and advised to seek
professional medical assistance. NOTE: When in the club, please adhere to our on-site procedures regarding infection
control, i.e. social distancing, hand washing / hand sanitising and general coughing / sneezing etiquette

Comment *

Prior to submitting this application, we would also like to note that if you are on the vulnerable persons list, you are kindly advised to see your GP in order to continue practicing/ teaching.
As a guidance, so far the meaning of vulnerable in relation to COVID-19 is:

are 70 or older
have a lung condition that's not severe (such as asthma, COPD, emphysema or bronchitis)
have heart disease
have diabetes
have chronic kidney disease
have liver disease (such as hepatitis)
have a condition affecting the brain or nerves (such as Parkinson's disease, motor neurone disease, multiple sclerosis or cerebral palsy)
have a condition that means they have a high risk of getting infections
are taking medicine that can affect the immune system (such as low doses of steroids)
are very obese (a BMI of 40 or above)
are pregnant

Submit

Our goal is to maintain high standards, to grow and to help all our students achieve their personal goals and aspirations. Tang Soo Do fosters the development of spiritual qualities: courage, courtesy, integrity, humility and self-control.

E.T.S.D.F
President & European Chief Instructor

European I.M.A

GMN
Telephone number

GMN
+353 87 696 9215

Email

[email protected]