COVID-19 Screening Form

Email: *

Phone Number: *

Do you have a confirmed diagnosis of COVID-19? *
YesNo

Are you waiting for a COVID 19 test or the results, or considered a probable case, or been asked to self-isolate? *
Waiting for the testWaiting for the resultI am considered a probable caseI have been asked to self-isolateNone of the above

Do you have new or worsening symptoms of the following (can choose one or more)? *
CoughSore throatShortness of breathRunny nose, sneezing, post-nasal dripTemporary loss of smellFeverNone of the above

Do you have any of the following symptoms that are not related to another diagnosis? *
Fever onlyDiarrhoeaHeadacheMuscle painNausea/vomitingNone of the above

Have you had close contact with other people in the last 14 days who are probable or confirmed to have COVID 19? *
YesNo

Have you travelled overseas in the last 14 days? *
YesNo

Have you worked on an international aircraft or shipping vessel (this includes cleaning staff) in the last 14 days? *
YesNo

Have you exited from an MIQ facility in the last 14 days? *
YesNo

Have you stayed in or travelled from an area with a growing COVID community outbreak in the last 14 days? *
YesNo

Have you had direct contact with someone in the last 14 days who has travelled overseas? *
YesNo

Have you had a direct contact with any one of the following people in the last 14 days? *

• Border staff (international flights)

• Quarantine and isolation facility staff

• International aircraft and shipping vessel crew

YesNo

Have you been to an international airport or maritime port in areas/conveniences visited by international arrivals in the 14 days? *
YesNo

In the last 14 days, have you worked in cold storage areas of facilities that receive imported chilled and frozen goods directly from an international or maritime port? *
YesNo

Have you been to one of the locations of interested listed by the Ministry of Health (please click here to follow the link) in the last 14 days? *
YesNo

If you have been to any of the locations, please provide exact dates and the locations.

Have you received COVID 19 vaccines? *
1st dose onlyBoth dosesNo

If you have only had the 1st dose of the COVID 19 vaccine, please provide us with the date that you were vaccinated.

I have answered all questions above to the best of my ability and I certify that the information submitted in this application is true and correct to the best of my knowledge. *
Yes