Travel Declaration

Travel Declaration
You may 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
Phone Number
E-mail
example@example.com
Department *
Company *
Company Other
Date Of Travel *

Day Month Year
Date
Address travelled from (away) Outside Broken Hill *

Street Address

Street Address Line 2

City State

Post Code
Return Date, To Broken Hill from Away *

Day Month Year
Date
Did you travel from *

Victoria (VIC) * South Australia (SA) * Within the area bounded by Lithgow, Gosford, Wollongong and Goulburn (NSW) * No, I traveled outside of the areas listed above
If yes to * above testing date

Day Month Year
Date
Shift When Testing is Required

Day Night
A reminder to all workers, any travel must be in line with Government guidelines.
I understand that I may 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
Isolation Date

Day Month Year
Date
Should be Empty: