Title Page
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Conducted on
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Prepared by
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Customers address
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Customers contact details
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Have you been in, or transited through, mainland China or Iran in the past 14 days, returned from South Korea on/after 5 March 2020, or returned from Italy on/after 11 March 2020 ?
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do not attend site
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Have you travelled anywhere internationally and been subject to the Federal Government Guidelines to self-isolate (implemented 16.3.20) in the last 14 days?.
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do not attend site
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Have you been in CLOSE or CASUAL contact with a confirmed case of COVID-19?
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do not attend site
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Are you ill in hospital with pneumonia, or is any family member that lives in your home, been ill in hospital with pneumonia?
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do not attend site
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Are you or anyone that resides in the home experiencing fever or respiratory symptoms?
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do not attend site
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If things change in the household the client has agreed to contact claytons and advise
Sign off
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Claytons to sign
