Your Name*

Company Name*

Your Email Address*

Your Phone Number*

This section covers your planned visit to a premise at College Group. Please complete all the details of the on-site visit to the premises.

Please choose from the following options of premises at College Group*
—Please choose an option—College Proteins, College, Nobber, Co.Meath, A82 XT61College Biofuels, College, Nobber, Co.Meath, A82 XT61Farragh Proteins, Monnery Upper, Crossdoney, Co.Cavan, H12 X7P9

Date of Planned Visit*

Estimated time of arrival*
—Please choose an option—7.00am7.30am8.00am8.30am9.00am9.30am10.00am10.30am11.00am11.30am12.00pm12.30pm13.00pm13.30pm14.00pm14.30pm15.00pm15.30pm16.00pm16.30pm17.00pm

Estimated time of departure*
—Please choose an option—7.00am7.30am8.00am8.30am9.00am9.30am10.00am10.30am11.00am11.30am12.00pm12.30pm13.00pm13.30pm14.00pm14.30pm15.00pm15.30pm16.00pm16.30pm17.00pm

Purpose of visit to selected premises*

College Group Contact Name*

If your response to questions on this form is indicative that you may have symptoms of COVID-19, have been in close contact with a confirmed case of Covid-19, or you have been abroad in the last 14 days with the exception of Northern Ireland, you are prohibited from entering the intended College Group premises at this time and advised to follow HSE guidance on the matter. If you develop Covid-19 symptoms post completion of this form, or in the hours before your visit, please refrain from entering the premises. If you develop symptoms whilst on the premises, please inform a member of staff who will contact the Covid-19 Response Management Team for the premises.

Have you returned from abroad in the last 14 days (excluding Northern Ireland)?*
—Please choose an option—YesNo

Do you have flu like symptoms – aching, sneezing, chills, lack of taste or smell?*
—Please choose an option—YesNo

Do you have a temperature of 38C or more?*
—Please choose an option—YesNo

Do you have a persistent cough not attributed to an existing medical condition?*
—Please choose an option—YesNo

Do you have difficulty in breathing, or shortness of breath not attributed to an existing medical condition?*
—Please choose an option—YesNo

Have you sought medical advice in relation to any of the symptoms above in the past 14 days?*
—Please choose an option—YesNo

Safely Protocol for Access to College Group Site/Premises
You are required by the terms of the Return to Work Safely Protocol to complete a short induction in relation to infection control and prevention. Please confirm you have completed one or both of the of the following statements: For more information on Covid-19, please visit the HSE Coronavirus (COVID-19) https://www2.hse.ie/coronavirus/

I have watched the HSE videos in relation to Covid-19 Coronavirus infection control provided below*
href=https://www.youtube.com/watch?v=5JYhm9oa-DM
YesNo

I have read the HSE Covid-19 information booklet*
https://365learning-my.sharepoint.com/:b:/g/personal/bmonaghan_365learning_ie/EdCit8ZBXxtIlD5ktqDq6GQB2mnX9Lp4S8gAMZn88tCPfw?e=j23QDD
YesNo

I certify that the information submitted in this application is true and correct to the best of my knowledge. You are expected to adhere to the onsite standard hygiene processes in place regarding infection control. i.e. hand washing, hand sanitizing, and general coughing/sneezing etiquette.
I confirm that I have read, understood and completed all sections of this form to the best of my knowledge