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Covid-19 Declaration
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Street Address
Address Line 2
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Date Provided
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Please answer the following questions to the best of your knowledge.
Answers to all questions are required.
Is anyone who lives at your address currently under any form of self-isolation as the result of an order of any government authority or as the result of a recommendation of a health professional?
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Yes
No
In the last 14 days, has anyone who lives at your address been in physical contact with anyone who has been diagnosed with the COVID-19 virus?
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Yes
No
In the last 14 days, has anyone who lives at your address been in physical contact with anyone who is in self-isolation due to the COVID-19 virus?
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Yes
No
Has anyone who lives at your address returned from overseas or interstate within the last 14 days?
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Yes
No
In the last 14 days, has anyone who lives at your address experienced flu-like symptoms (sore throat, fever, tiredness, cough) following overseas travel and/or physical contact with someone who has recently returned from overseas or interstate?
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Yes
No
Declaration
I confirm that I have read the Privacy Collection Notice below and that I consent to provide the information above, which I certify is accurate to the best of my knowledge.
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Yes - I understand and agree with the above
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