Dear Resident, A State of Emergency was declared in Victoria on the 16th March 2020 to combat COVID-19. You must self-quarantine (self-isolate) for a period of at least 14 days if you have: • arrived in Australia after midnight on 16th March 2020; • been diagnosed with COVID-19; and/or • been in contact with someone who has been diagnosed with COVID-19. Self-quarantine (self-isolation) means that you must stay in your room at Graduate House (including Barkly Place and Barry Street). It means that you must NOT: i. leave your room; ii. invite anyone into your room; and iii. use shared Graduate House facilities, such as the kitchen, dining room, library or games room. You may need medical care while in isolation – please email email@example.com or telephone 9347 3428 to discuss this need. We will then work with you to leave your room under STRICT supervision or assist you in giving access to a health professional to come to your room. In an emergency, you may be required to evacuate. We ask that you try to keep at least 1.5m away from all other residents when evacuating and when gathering in the designated evacuation space. We require your completion, signing and return of a declaration. Your privacy is important to us. In providing the information in this form, you consent to our collection, use, processing, transfer, and/or disclosure of your personal data, including any sensitive data, in accordance with all applicable laws for the purposes of: • monitoring, evaluating, and responding to the COVID-19 outbreak; • providing accommodation and services in Graduate House having regard to Public Health Agency guidelines, and, to the extent necessary, for the safety of our residents and staff; and • providing information to Public Health Agencies, medical personnel and any other relevant governmental agency. If you decide not to complete this declaration form, we reserve all rights to exclude you from residency at Graduate House and/or evict you from Graduate House. Thank you for your understanding and cooperation.Question 1: Arrived in Australia on the 16th March 2020 (anytime after midnight on the 15th March 2020)?YesNoAttach ProofAccepted file types: pdf.Question 2: Are you required to self-quarantine because you arrived in Australia after midnight on 15 March 2020 or because of your travel history?*YesNoQuestion 3: Have you had close contact with someone who is diagnosed with or suspected of having COVID-19 in the past 14 days?*YesNoQuestion 4: Do you have any reason to believe that you have or may have COVID-19?*YesNoQuestion 5: Have you been in self-isolation previously?*YesNoCountry of self-isolation*AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweStart date of isolation* DD MM YYYYEnd date of isolation* DD MM YYYYSelf-isolationYou have answered Yes in the questions above and you MUST self-quarantine (self-isolate) for 14 days.The degree to which we can support self-isolation varies across our accommodation wings: Terrace wing (222-234 Leicester Street) – we are not able to support self-isolation in this wing at all as there are no bathrooms in these accommodation rooms. Central wing and southern (Stella Langford) wing (210-220 Leicester Street) – we are able to support self-isolation through the provision of breakfast every day and dinner Monday to Friday delivered to your room. Barry Street and Barkly Place – we are not able to support self-isolation at this time in this wing as we are not able to deliver meals safely. Self-isolation means that you are not able to leave your room – it is thus not possible for you to collect deliveries from the downstairs foyer. You may also be required to self-isolate if you are already a resident, if you: • become ill with COVID-19 related symptoms; • are tested for or diagnosed with COVID-19; • become aware of the need to self-quarantine while staying at Graduate House; or • become aware of the need to self-quarantine within 14 days of your stay, please inform us immediately by email firstname.lastname@example.org or by telephone on 9347 3428 if any of the above occurs.. Please also follow the advice of https://www.dhhs.vic.gov.au/coronavirus.Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Room No:*Arrival date in Australia* DD MM YYYYI agree that All information that I have provided is complete and correct. I am aware that missing or incomplete information, whether deliberate or the result of negligence, may exclude me from residency at Graduate House and/or result in eviction from Graduate House. I will abide by self-quarantine (self-isolation) requirements for 14 days and will not have any guests in my room during this required isolation period. I will inform Graduate House reception within ONE HOUR if I become ill with COVID-19 related symptoms I will inform Graduate House reception within ONE HOUR if I or a medical professional request(s) that I undertake a COVID-19 test I will inform Graduate House reception within ONE HOUR if I am tested for or diagnosed with COVID-19 I will inform Graduate House reception within ONE HOUR if I become aware of the need to self-quarantine while staying at Graduate House I will inform Graduate House reception within ONE HOUR if I become aware of the need to self-quarantine within 14 days of my stay. I understand that I may need to change rooms should there be a requirement for me to self-isolate and that this will be subject to availability; I am aware that I may be fined up to $20,000 if I do not undertake required self-quarantine for 14 days OR if I invite/have someone in my room during a required isolation period.Signature*Date of Signature* DD MM YYYYEmailThis field is for validation purposes and should be left unchanged.