COVID Declaration Form

Employment

Who are you employed by?*

Card Access Number (Printed on your ID card)*

I don't have an access card

Self Declaration

In the last 72 hours, have you experienced flu like symptoms or been tested for COVID-19 and are waiting for results?*

Yes
No

Have you been in contact with a confirmed case of Coronavirus in the past 7 days?*

Yes
No

Date of contact:*

Details of contact:*

In the last 7 days, have you been to Metropolitan Melbourne?*

Yes
No

If yes, what Location?*

If yes, when?*

In the last 7 days, have you been directed to self-isolate or self-quarantine by an authorised officer?*

Yes
No

In the last 7 days have you worked for another employer at any facility, work site or factory?*

Yes
No

If yes, which employer?

Personal Details

Name*

First Last English Name (if Applicable)

Email*

Enter Email Confirm Email

Mobile Phone

Please specify your Employer/Business*

Reason for visit*

Who is your Midfield / UDC contact person*

Acknowledgement

I understand that if I give false or misleading information on this declaration the company will consider my actions to be a serious safety breach/serious misconduct and I will be liable to instant dismissal. I acknowledge that it is my responsibility to self-report to the workplace prior to starting any shift any of the following: 1) I have experienced COVID-19 related symptoms within the last 72 hours 2) I have been in contact with a confirmed case of COVID-19 3) I have been directed to self-isolate or self-quarantine by an authorised officer. This form needs to be completed prior to commencing work at the start of each week. I understand that if I refuse or fail to complete this form prior to commencing work for the week that I will be liable to instant dismissal due to serious misconduct.

Acknowledgement

I understand that if I give false or misleading information on this declaration the company will consider my actions to be a serious safety breach/serious misconduct and I will be liable to my contract being cancelled. This form needs to be completed prior to commencing work. I understand that if I refuse of fail to complete this form prior to commencing work that I will be liable to my contract being cancelled.

Understanding and Acknowledgement

Understanding and Acknowledgement*

I understand

Note:

Employment

Self Declaration

Personal Details

Acknowledgement

Acknowledgement

Understanding and Acknowledgement

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