Covid-19 Safety Form

Are you double vaccinated?
YES
NO
Wish not to disclose

Have you been feeling unwell,
YES
NO

Or have you had any of the following symptoms?
Fever or temperature now or in the past 3 days?
Sore throat, cough or shortness of breath?
Runny/stuffy nose or other respiratory symptoms?
Loss of smell or taste
Others

Have you, or person with whom you live, been asked to quarantine due to:
YES Attending an area identified as high risk for community transmission.
NO

Interstate or international travel?

If YES, when does your quarantine period end? / /

Have you, or a person with whom you live, been asked to self-isolate white waiting for COVID-19 test results?
YES
NO

Do you, or a person with whom you live, work, in a medi-hotel used for quarantine?
YES
NO

Are you, or a person with whom you live, an essential worker who is travelling interstate? (e.g. freight, transport, removalists, aircrew).
YES
NO

Entry Log List

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