COVID-19 Declaration

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: