Travel Declaration

Travel Declaration
You will be required to attend the Perilya COVID-19 Point of care clinic (located at the 115 Wentworth Road, Broken Hill) on the first rostered day of your panel.
Today's Date

Day Month Year
Employee Number
If you are a visitor put in "V"
Your Name *

First Name Last Name
Mobile Number
Phone Number
E-mail
Department *
Company *
Company Other
Date Of Travel *

Day Month Year
Date
Broken Hill Address *

Street Address

Street Address Line 2

City State

Post Code
Address Travelling to, Away from Broken Hill *

Street Address

Street Address Line 2

City State

Post Code
Return Date, To Broken Hill from Away *

Day Month Year
Date
Date of first Panel/Rostered working day, after return to Broken Hill *

Day Month Year
Date
Shift for First Panel / Rostered working day *

Day Night
A reminder to all workers, any travel must be in line with Government guidelines.
I understand that I will be required to submit to a COVID-19 Point of care test (requires a single drop of blood) *

Yes No
I declare the above to be true and correct. *

Yes
Approved

Yes No
Completed

Yes No
Should be Empty: