COVID-19 Declaration

Address

E-mail
Department *
Today's Date

Day Month Year
Have you been in close contact with someone that has been diagnosed or suspected case of COVID-19?

Yes No Unknown
Do you currently have any of these symptoms

Fever (Temperature above 37.5° C) Cough Sore throat Tiredness Shortness of breath
Have you travelled > 100 km from Broken Hill within fourteen (14) days? *

Yes No
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Have you travelled internationally in the past fourteen (14) days? *

Yes No
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Day Month Year
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Departure Date:

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Should be Empty: