Attestation of Staff and Visitors - East Grampians Health Services

Please answer the following screening questions truthfully to help prevent the spread of COVID-19.

First Name*

Last Name*

Daytime Telephone Number*

Type*

Visitor
Contractor

Do you have any of the following symptoms: Fever, Cough, Runny/Blocked Nose, Sore Throat, Breathing Difficulties/Breathlessness, Fatigue/Tiredness, Loss of Smell/Taste, Muscle Pains/Aches?*

Yes
No

Are you?*

Unvaccinated (no or one dose of vaccine)
Vaccinated (two or more doses of TGA approved vaccine)

Are you currently required to self-isolate or awaiting a COVID -19 test result?*

Yes
No

My temperature is above 37.5*

Yes
No

Please select the location you are heading to:

Please select your work location:*

Other Locations*