Get Social..
Name (required)
I am a (required) PatientCarer accompanying patientProfessional Visitor
Approximate Length of stay (required) less than 15 minutes30 minutes1 hour3 hoursmore than 3 hours
Date of Birth (required)
Phone number (required)
Have you had or been exposed to a person with an COVID -19 in the past 14 days? YesNo
Have visited, lived or worked at a location with a recognised outbreak in the past 14 days? YesNo
Have you had CLOSE* or CASUAL** contact with a confirmed case of COVID-19? CloseCasualNo
Have you had contact with someone who has been in quarantine as a close contact of someone with COVID-19 in the past 14 days? YesNo
Are you a health or aged care worker with recent onset of the COVID-19 symptoms? YesNo
Are you a resident of an aged care facility? YesNo
*CLOSE defined as: Spending > 15 minutes face to face OR sharing a closed space > two hours with a person who is a confirmed case 48 hours before they showed symptoms or once they showed symptoms.
** CASUAL defined as: Spending < 15 minutes face to face OR sharing a closed space < two hours with a person who is a confirmed case 48 hours AND had symptoms at the time.
Have you recently tested positive for COVID-19? YesNo
If Tested: Date
Time
Have you travelled overseas in the past 14 days? YesNo
If Yes: Where
Do you have any of the following symptoms:
Cough YesNo
Sore throat YesNo
Shortness of breath YesNo
Chills YesNo
Recent loss of sense of smell or taste YesNo
Any other respiratory symptoms including a runny nose? YesNo
Please go to the reception desk to have one of our Admin staff take your temperature, enter your temperature below. (required)
