Daily 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
Department
*
Administration
Contractor
Exploration
HSE&T
Maintenance
Mining Nth Ops / North Mine
Mining Nth Ops / Potosi Mine
Mining Sth Ops
Process
Technical Services
Company
*
Perilya
Atlas Copco
Aus-mining
Boart longyear
Cav Power
CoreStaff
CMC
Diverse Drilling
Fillerys
Flat Out Tyres
Jetcrete
Lawrence Eng
Minesite Labs'
MCA
Nejaims
Pacific National
Promec
Sumtin
Swick
Other
Company Other
*
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Minutes
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AM/PM Option
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
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 been in CLOSE contact (>15 minutes exposure) with a known source of COVID-19?
*
Yes
No
Have you been in CLOSE contact (>15 minutes exposure) with a person who has "flu-like" symptoms?
*
Yes
No
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.
Submit
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