Third Floor

Donnybrook House
36-42 Donnybrook Road
Dublin 4
D|RES Properties COVID-19 (Coronavirus) Self-Declaration
Due to the COVID-19 pandemic, and in the interest of the health of you, your family, all those working on D|RES Properties, and
the wider community we require all operatives to answer the following questions before returning to work. These questions are
based on HSE, Government, and CIF advice, and must be answered honestly.

All completed declarations must be submitted to D|RES Properties 48hrs in advance of attending site, failure to do this shall result
in you being denied entry by security.

In the past 14 days Yes No

Have you or has anyone you come into close contact with been confirmed as having or is awaiting test results for ☐ ☐
COVID-19 (Coronavirus)?

If Yes, what was the last date you had close contact with this person? Click or tap to enter a date.

Have you or anyone you have come into close contact with currently or in the last 14 days felt unwell and experienced ☐ ☐
any cold or flu-like symptoms. Such as a fever / high temperature (at least 38 degrees C), persistent coughing,
shortness of breath, difficulty breathing, fatigue, headaches, runny nose, sore throat?

If yes, on what date did you and/or they last display symptoms? Click or tap to enter a date.

Have you or anyone you have come into close contact with currently or in the last 14 days been advised by a GP to self- ☐ ☐
isolate?

If yes, on what date were you and/or they instructed to start isolation from? Click or tap to enter a date.

Have you recently returned from overseas travel, or recently entered mainland Ireland? ☐ ☐

Click or tap here to Date of return to

If yes, Country/location travelled from: Click or tap to enter a date.
enter text. Ireland:

Within the last 14 days, have you been in close contact with any persons who have recently returned from overseas ☐ ☐
travel or recently entered the Republic of Ireland?

Country/location Click or tap here to Date of return to Click or tap to enter a

If yes,
travelled from: enter text. Ireland: date.

If you have answered “Yes” to any of the questions above you must not attend any D|RES Properties
project site for a period of time as directed by a doctor, HSE or other government agency.

I (the undersigned) declare that I have answered the above questions truthfully and to the best of my knowledge and I will advise
my employer and/or D|RES Properties immediately of any changes to the above statements.

Furthermore, I understand that by giving false or misleading answers to the above questions or failing to notify my employer where
an answer changes is improper conduct that is likely to endanger the safety, health and welfare at work of myself and that of other
persons working on this project, in breach of the Safety, Health and Welfare at Work Act 2005 (Section 13).

I also consent to D|RES Properties sharing the information provided only for the purpose of Health & Safety and limiting the spread
of COVID-19 (Coronavirus) through contact tracing.

Full name: (please print) Contractor Name:

Signature: Date:

This document is confidential and may be privileged or otherwise protected by law. Only the intended recipient is authorised to access this me ssage. If you
are not the intended recipient, please notify the sender immediately; you should not copy this document or disclose its contents to anyone.