Health Questionnaire

COPE Galway Business Sleep Out

COVID – 19 HEALTH QUESTIONNAIRE FORM

Do you believe you may currently have COVID-19?*

Have you had any of the following symptoms of COVID-19 in the past 14 days?

High temperature (over 37.5°C)*
Loss of sense of smell and/or taste*
New continuous cough*
New unexplained shortness of breath*

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*
Consent*
Consent*

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