Online Form - COVID-19 Visitor Screening Questionnaire

What is the name of the Shire staff member you are meeting with?*

Meeting date and time*

Your full name*

Your organisation (if applicable)

Your phone number*

Do you have, or have recently, displayed the following symptoms of COVID-19? Fever (≥37.50C) OR recent history of fever (e.g. night sweats, chills), without a known source OR acute respiratory symptoms (including cough, shortness of breath, sore throat, runny nose) OR acute loss of smell or taste.*

YesNo

Have you been in contact with a confirmed COVID-19 person or visited a confirmed COVID-19 exposure site in the past 7 days?*

YesNo

Have you been asked to self-isolate by the Department of Health?*

YesNo

In the past 14 days, have you been in close contact with anyone suspected of having COVID-19, or are you awaiting test results?*

YesNo

Proof of Vaccination is required for meeting with Shire Officers within the Administration Office, Civic Centre and Operations Centre. Are you able to provide Proof of Vaccination or exemption in the format specified by the WA State Government upon attendance at your meeting?*

YesNo