DML Electrical Solutions Pty Ltd - Covid-19 Electrical Services Consent Form
By submitting this form, you agree that a permitted worker under Victoria's Stage 4 COVID-19 restrictions from DML Electrical Solutions Pty Ltd is required to complete permitted or essential electrical work for you, the client.
Client Name
*
First/Last Name
Company Name
Site Details
*
Site Address
Works Required
By checking the boxes, you confirm that you agree with the following statements:
*
A COVID-SAFE plan is currently active at the site address where the electrical works are required
The works required are permitted under Victoria's Stage 4 COVID-19 restrictions.
For Residential Construction, there will be no more than 5 persons on site at any one time.
For Commercial Construction, there will be 25% of normal working capacity on site at any one time.
Do you or anyone on site have any of these symptoms? - cough, shortness of breath, high fever, muscle pain, body ache, nausea, loss of taste/smell
*
YES
NO
Within the past 14 days, have you or anyone on site been in contact with anyone that has COVID-19 symptoms or been infected?
*
YES
NO
Are you or anyone on site living with anyone that is infected or quarantined due to COVID-19?
*
YES
NO
Declaration
I acknowledge that the information I have given in this consent form is accurate and complete. By signing below, I confirm that I understand and agree to all terms and statements in this form.
Date
*
-
Day
-
Month
Year
Date
Signature
*
Submit
Should be Empty: