Staff Coronavirus (COVID-19) Health Questionnaire Each staff member should complete this questionnaire before starting each shift. Please provide your completed questionnaire to reception to keep as a record. Staff Name* First Last Date* MM slash DD slash YYYY Start time : Hours Minutes AM PM End Time : Hours Minutes AM PM Are you currently required to be in isolation because you have been diagnosed with coronavirus (COVID-19)?* Yes No Have you been directed to a period of 14-day quarantine by the Department of Health and Human Services as a result of being a close contact of someone with coronavirus (COVID-19)?* Yes No If you answered YES to either of the above questions you should not attend work until advised by the Department of Health and Human Services that you are released from isolation or until your 14-day quarantine period is complete.If you answered NO to the above questions, proceed to the symptom checklist belowAre you experiencing these symptoms?Fever (If you have a thermometer, take your own temperature. You are considered to have a fever if above 37°5C) Yes No Chills* Yes No Cough* Yes No Sore throat* Yes No Shortness of breath* Yes No Runny nose* Yes No Loss of sense of smell* Yes No If you answered YES to any of the above questions you should not enter your workplace (or should leave your workplace). Tell your employer, go home, and get tested for coronavirus (COVID-19). If you answered NO to all the above questions, you can enter your workplace.If you develop symptoms, stay at home and seek further advice from the 24-hour coronavirus hotline 1800 675 398 or your general practitioner. You are encouraged to download the COVIDSafe App to assist contact tracing. Staying apart keeps us together. For more information about Coronavirus (COVID-19), please visit vic.gov.au/coronavirusNameThis field is for validation purposes and should be left unchanged.
