Medical Declaration COVID-19 Checklist

Medical Declaration COVID-19 Checklist
Date

Day Month Year
Today's Date
This declaration MUST be completed at the start of every shift. Prior to mobilising to site.

Checklist Questions *

	Yes	No
Have you traveled overseas in the last 14 days ?
Have you been in a declared COVID-19 hotspot in the last 14 days ?
Have you traveled interstate in the last 14 days ?
Have you been in contact with a confirmed case of COVID-19 in the past 28 days ?
Do you currently feel unwell ?
Did your temperature self-test show a fever higher than 37.7 degrees Celsius ?

If the answer to any of the above questions is yes, please contact your supervisor immediately.
Employee Details *

First Name Last Name
Employee Signature *

Clear
Should be Empty: