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
Phone Number

Area Code 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/Location 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 When Testing is Required *

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 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
Isolation Date

Day Month Year
Date
Should be Empty: