Name
*
First
Last
Email
*
Mobile
*
Are you suffering from any of the following symptoms – fever, cough, sore throat, fatigue, difficulty breathing
*
No
Yes
Have you been in contact with anyone who has tested positive to COVID-19 within the last 14 days
*
No
Yes
Have you shared a residence with anyone waiting on test results for COVID-19 within the last 14 days
*
No
Yes
Have you personally been tested for COVID-19 and are awaiting the test results?
*
No
Yes
Have you been in a COVID-19 hotspot in the last 14 days or any of the venues listed on the NSW Health website
*
IF UNSURE VISIT
https://www.nsw.gov.au/covid-19/latest-news-and-updates#latest-covid-19-case-locations-in-nsw
No
Yes
Privacy Statement
Your contact details are being collected in accordance with the requirements of the NSW Public Health Order in response to the COVID-19 pandemic and will only be disclosed to NSW Health for contact tracing purposes. The contact details will be securely and confidentially stored for 4 weeks, after which they will be deleted.
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