Covid Form - Casa Online

The safety of our volunteers, clients, visitors, and families is our top priority. As the Coronavirus disease 2019 (COVID-19) outbreak continues to evolve and spreads globally, CASA is monitoring the situation closely and will periodically update our organisation’s guidance based on current recommendations from NSW Health.

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in the Brian Wunsch Centre. Thank you for your time and collaboration!

Visitor’s Name *

Visitor’s Phone Number (mobile / home) *

Visitor’s Address *

Visitor’s Email Address *

Visitor’s Company / Organization *

Name of CASA’s Program / Service *

Self-Declaration by Visitor

1) Have you travelled overseas and returned to Australia in the last 21 days? *YesNo

If yes, what date did you re-enter Australia? *

Travelled countries and cities *

2) Have you been in close contact with anyone who has traveled overseas within the last 14 days? *YesNo

If yes, do you know the countries travelled?

3) Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days? *YesNo

4) Have you had close contact with or cared for someone who has been tested for COVID-19 and are waiting for their results? *YesNo

5) Have you experienced any cold or flu-like symptoms in the last 14 days (including fever, cough, sore throat, respiratory illness, difficulty breathing and fatigue)? *YesNo

If you have answered “yes” to any of the above questions, access to the facility will be denied.

I declare that the information given in this document is true and complete to the best of my knowledge, and I understand that false information or failure to disclose information may affect me.

Visitor's Name *

Date *

Visitor’s Signature *

Note: If you plan to be onsite for consecutive days and your responses change, please immediately advise CASA. The information collected in this form will be used to determine your access to our facilities.

Access to FacilityApprovedDenied

Group Facilitator / Leader Name

Date

Signature

For more information, please see CASA’s Safety Plan

Any questions should be directed to admin@casaonline.org.au

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COVID-19 Visitor Questionnaire

COVID-19 Visitor Questionnaire

Self-Declaration by Visitor

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