COVID-19 Declaration
Employee ID number*
if you are a visitor please put a 'V' otherwise your man number/id
Your Name*
First Name Last Name
Phone Number
Mobile Number
Address
Street Address
Street Address Line 2
City State
Postal Code
E-mail
Department*
Company*
Company Other*
Today's Date
Day Month Year
Have you been notified (by CovidSafe or Health Authority) that you have been in contact with someone that has been diagnosed or a suspected case of COVID-19?*
Yes No
Have you experienced any of these symptoms in the last 7 days or do you have any of these symptoms Currently (tick the box for yes)?
Fever (Temperature above 37.5° C) Cough Sore throat Shortness of breath
Do you have the COVIDSafe app installed and active on your smartphone?
Yes, the app is installed and active on your phone.
I declare the above to be true and correct.*
Yes.
Should be Empty:

COVID-19 Declaration