Name *

First Name

Last Name

Phone *

(###)

###

####

Have you travelled Overseas in the last 14 days? *

Yes

No

Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days? *

Yes

No

Have you been in close contact with anyone who has travelled outside of Australia within the last 14 days? *

Yes

No

Have you been in close contact with anyone who has travelled on a cruise ship within the last 14 days?

Yes

No

Have you experienced any cold or flu-like symptoms in the last 14 days (including fever, cough, sore throat, respiratory illness, difficulty breathing)?

Yes

No

Are you currently required by government and/or health authorities to be self-isolating or quarantining yourself? *

Yes

No

I confirm the above information is true and accurate to the best of my knowledge *

Yes