Covid-19 Screening Form

Have you returned from overseas in the past 21 days?

Have you travelled from Victoria in the last 14 days?

Have you travelled from a Sydney hotspot in the last 14 days?

Have you had contact with a confirmed case of Coronavirus in the last 14 days?

Do you have one or more of the following symptoms?

Confirmation

I have read the above information and answered the questions truthfully to the best of my knowledge.

Name *

First

Last

Date