Health & Travel Declaration - Calvary Community Care (C3)

Health & Travel Declaration

Full Name*
Contact Number*
Current Location*
Do you currently have any of/are on medical leave for the following symptoms: cough, sore throat, runny nose, breathlessness?*
- Yes
- No
Have you had close contact** with someone who is on Stay Home Notice or Home Quarantine Orders in the last 14 days?*
**close contact = within a 2-metre radius
- Yes
- No
Have you travelled overseas or had close contact with anyone who travelled overseas in the past 14 days?*
- Yes
- No
Personal Data Consent*
By providing this information, you agree to Calvary Community Care collecting, using and disclosing your personal data for the purposes of processing this declaration and contact tracing (if necessary).
- I agree
- I disagree