Covid-19 Screening Checklist

Covid-19 Screening Checklist
During and Government Mandated Lockdown, or prior to entering any high risk facilities, you must complete the following form

High risk premises include locations such as Nursing Homes, Hospitals, Public Venues or wherever you are required to complete a Covid-19 declaration

Are you exhibiting any of the following symptoms*

Have you been in close contact with anyone confirmed with Covid-19 or who has been sent for Covid-19 Testing and is awaiting results*

YESNO
Have you been to a declared Covid-19 exposure site in the last 14 days*

YESNO
At all times whilst onsite, you agree to abide by the following guidelines:
- wash hands with soap & water or alcholol sanitiser prior to entering the property
- Practice social distancing - remain 1.5m away from other people at all times
- cough into elbow or tissue (that is then immediatly disposed of)
- adhere to any directional signange
- follow instructions of internal staff at the property
- follow any government mandidated guidelines such as mask wearing guidelines etc
You also agree to minimise contact with clients & other persons onsite at all times
Which State are you working In?*

QLDNSWVIC
Your Name*

First NameLast Name
Your Email*
example@example.com
Date*

DayMonthYear
Date
Hour Minutes
YOU HAVE SELECTED AN OPTION THAT COULD INDICATE YOU HAVE BEEN IN CONTACT WITH A CASE OF COVID-19 OR YOU HAVE SYMPTOMS OF COVID-19.

DUE TO THIS YOU MUST NOT ATTEND WORK AND MUST CONTACT YOUR SUPERVISOR IMMEDIATLY.

YOU SHOULD ALSO GO FOR A COVID-19 TEST AND REMAIN AT HOME UNTIL YOU HAVE RECEIVED A NEGATIVE RESULT.
By Submitting this form, you will receive an email which will act as your permit to work should you be required to prove you are an essential worker by Government Officials.

If you have any questions, please contact your manager.
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