Health Questionnaire Back to Participant Resources Hub COPE Galway Business Sleep Out COVID – 19 HEALTH QUESTIONNAIRE FORM Name* Organisation* Can you please indicate your current temperature:* Do you believe you may currently have COVID-19?* Yes No 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 join the Business Sleep Out on 3 December at 6pm. Consent* I confirm that the details above are true to the best of my knowledge*Consent* I understand the risks involved in participation, am participating on a voluntary basis and that I may opt-out at any time.*Consent* I agree to inform COPE Galway Business Sleep Out organisers, named below, should I develop any symptoms of COVID-19 and will not participate in the Business Sleep Out.*COPE Galway Business Sleep Out Organising Team: Sharon Fitzpatrick, Head of Development. sfitzpatrick@copegalway.ie 087 912 0853 Leonie Woutersen, Senior Fundraising Executive. lwoutersen@copegalway.ie 085 876 4641
