Travel Declaration
ONLY REQUIRED if you travelled Within the area bounded by Lithgow, Lakes Entrance, Wollongong and Goulburn (NSW) *
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
*
Please Select
Visitor
Administration
Contractor
Exploration
HSE&T
Maintenance
Mining Nth Ops / North Mine
Mining Nth Ops / Potosi Mine
Mining Sth Ops
Process
Technical Services
Company
*
Please Select
Perilya
Atlas Copco
Aus-mining
Boart longyear
Cav Power
CoreStaff
CMC
Diverse Drilling
Fillerys
Flat Out Tyres
Jetcrete
Lawrence Eng
Minesite Labs'
Nejaims
Pacific National
Promec
Sumtin
Swick
Other
Company Other
Date Of Travel from Nominated Area
*
-
Day
-
Month
Year
Date
Address travelled from (away) Outside Broken Hill
Street Address
Street Address Line 2
City
State
Post Code
I have traveled from
*
Within the area bounded by Lithgow, Lakes Entrance, Wollongong and Goulburn (NSW) *
Return Date, To Broken Hill from Away
*
-
Day
-
Month
Year
Date
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 will be required to site Isolate for 14 days from Date Of Travel from Nominated Area (if traveled from 0700am 22nd December)
*
Yes
No
I declare the above to be true and correct.
*
Yes
Approved
Yes
No
Completed
Yes
No
Isolation Date
/
Day
/
Month
Year
Date
Submit
Should be Empty: