COVID-19 Daily Declaration Record

BEFORE entering any building/construction site/ALD premises, this form must be completed by each individual DAILY. Once you submit this form, it will be automatically sent to the site manager.

To help protect the health and wellbeing of everyone, if you answer ‘YES’ to any of the following questions please DO NOT ENTER or step foot into the building/site/ALD office:

Project Name/Address (Please ensure you put the project address, not just the builder name) *

STATE:

VIC NSW ACT QLD

Have you or anyone in your household returned from ANY COUNTRY overseas? *

Yes No

In the last 14 days: Have you or a household member visited Blacktown, Bayside, Burwood, Camden, Campbelltown, Canada Bay, Canterbury-Bankstown, Cumberland, Fairfield, Georges River, Hornsby Shire, Hunters Hill, Inner West, Ku-Ring-Gai, Lane Cove, Liverpool, Mosman, Northern Beaches, North Sydney, Parramatta, Penrith, Randwick, Ryde, Strathfield, Sutherland Shire, City of Sydney, The Hills Shire, Waverley, Willoughby, Wollahra, Black Rock, Brighton, Doveton, Glen Waverley, Mordialloc, Oakleigh, Cape Schank, Cheltenham, Forest Hill, Fountain Gate Shopping Centre, Hallam, Lakes Entrance, Mentone, Moorabbin, Wonthaggi? *

Yes No

Have you or a household member had close contact with someone confirmed to have COVID-19? *

Yes No

Have you have close contact with someone suspected to have COVID-19? *

Yes No

Does a member of your house hold have relevant symptoms, feel unwell or be undertaking a COVID Test or are waiting Results?

Yes No

Do you have cold or flu-like symptoms? (Fever, sore throat, cough, tiredness, difficulty breathing)? *

Yes No

If yes, please provide details:

If you have selected yes to any of the above, you must not enter site, you must immediately report to your manager and you are required to go for immediate testing and remain in isolation until testing results have been confirmed.

I declare the above is true, I’m fit to start work today and will abide by the COVID-19 requirements of maintaining a high level of hygiene and social distancing as per ALD requirements.

Name *

First Name Last Name

Temperature - If temperature is greater than 37.7 degrees, you must not enter site and report to management immediately

Phone Number *

Employer *

Occupation *

Date *

Date

Signature *

Clear