WDHS Request for Quarantine Exemption

1

Exemptions

Workers who are close contacts (meaning household or household-like contacts) may be exempt from quarantine requirements in order to attend work - so long as conditions are met, and their attendance is necessary for continuity of operations.

Who does this apply to:

Those who are close contacts who have no symptoms

What does the exemption cover?

Allows the staff member to work onsite with conditions but when the staff is not at the workplace staff must otherwise comply with all quarantine requirements.

*Please note these conditions are subject to change as directed by the Department of Health & Human Services

2

Have you advised WDHS Infection Prevention & Control Team that you are a close contact?* This field is required.Infection Prevention and Control Team contact number 5551 8246

YESNO

3

Have you received approval from Infection Control and your Divisional Head?* This field is required.

YESNO

4

Please contact Infection Prevention and Control Team on 5551 8246 to discuss.

5

Please select which role applies to you* This field is required.

allied health professional

medical practitioners, nurses and midwives

other healthcare worker

residential aged care worker

support service worker

6

Please state which department or facility you will be working * This field is required.

7

Please enter your Department Head's email addressPlease make sure the email is correct

name.surname@wdhs.net

8

Please provide date you were first advised of being a close contactPlease change

Date

9

Please explain why you are requesting an exemption & provide staff living arrangements, if applicable* This field is required.eg. is the staff member able to isolate from the infected house contact

10

Please enter your full name* This field is required.

First Name

Last Name

11

Please add your date of birth

Date

12

Do you have a personal email address so that you can be contacted?* This field is required.

YESNO

13

Please provide your email addressPersonal email is preferred so that you can be contacted about your request. If no email please

example@example.com

14

Please add a contact phone number

15

Conditions upon approval

If you are given approval to work onsite at Western District Health Service staff must

undertake a daily rapid antigen test for 5 days and return a negative result prior to commencing work;
wear an N95/P2 face masks at all times while at work and while travelling to and from work;
must not enter shared break areas with other workers; and
must not share facilities or amenities with other staff if possible, and follow all employer directions if they must use shared facilities

You will need to complete Rapid Antigen Testing and report any positive results using the WDHS Rapid Antigen Testing Reporting form. This form can be accessed on your phone or from home on the WDHS website under Staff Links section (bottom of page).