COVID-19 Tracing - Robyn Tyler

Date of Course*

Location of Course*

Name of work premises/public course premises*

First Name*

Last Name*

Phone Number*

Email*

In the last 2 weeks, have you experienced any of these symptoms? Fever Shortness of breath Dry Cough Tiredness Any other COVID or Flu symptoms*

Yes

No

In the last 14 days have you been in close contact or exposed to any person suspected of or confirmed with COVID-19?*

Yes

No

Have you taken an international or domestic flight within the last 14 days?

Yes

No

Have you returned from an overseas trip or returned from any coronavirus hot spots (eg Victoria, areas in NSW or been in any hotspots as indicated by Qld Health) in the last 14 days?*

Yes

No

I understand if I have answered "Yes" to any of the questions above I MUST let the trainer know ASAP.*

I understand

I do not understand

I declare that the information I have given is true, correct, and complete. I am aware that I may be held liable for knowingly providing incorrect information. I also voluntarily and freely consent to the collection and sharing of the above personal information only in relation to COVID-19 measures, in accordance with the Data Privacy Act.*

I agree

I disagree

COVID-19 Tracing - Robyn Tyler

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