Attestation of Staff and Visitors
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:
Café Pyrenees
Community Centre
Day Centre
Dialysis
Garden View Court
Lowe Street
Meeting
Oncology
Pathology
Patient Ward
Pre-admission
Pyrenees House
Radiology
Stores
Support Services
Theatre
The Nest
UCC
Willaura
Other
Please select your work location:
*
2nd floor
Café Pyrenees
Community Centre
Community Nursing
Day Centre
Dialysis
Garden View Court
IPU\Patient Ward
Kitchen
Lowe Street
Main Reception/Finance/Medical Records
Oncology
Pre-admission
Pyrenees House
Radiology
Stores
Support Services
Theatre\DPU
The Nest
UCC
Willaura
Other
Other Locations
*