Title Page
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Conducted on
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Date of Birth
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Prepared by
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Project Site
Before attending any construction sites/workplaces, I declare the following in true and correct:
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I am feeling unwell and have flu-like symptoms (such as fever, cough, shortness of breath, sore throat, sneezing and/or runny nose)
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I have a medical condition (including but not limited to poorly controlled diabetes or high blood pressure, cardiovascular disease or chronic respiratory disease)<br>or immunosuppression (a compromised immune system) that would place me<br>at a greater risk of serious illness if infected with coronavirus
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have travelled outside of Australia within the past 14 days or been in close contact with a person who has returned from overseas in the past 14 days
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I have been in contact with someone who has (or is suspected to have) coronavirus
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I am an Aboriginal or Torres Strait Islander who 50 years or older and have a chronic medical condition (or conditions).
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I am 65 years or older and have a chronic medical condition (or conditions)
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I am 70 years or older
If you have answered ‘yes’ to any of the above, you must not attend or access the site, and must immediately contact your Manager. If you answered ‘no’ to all of the above:
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I have spoken to my Manager prior to attending site
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I understand the current Visiting Work Sites Safely protocols
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have where possible advised the nominated contractor representative of my requirement to visit site
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I understand the use of mandatory PPE and note the hygiene/disinfection supply requirements in the protocol and will ensure they are available for my use.
