COVID-19 SYMPTOMS CHECKLIST FOR PLACEMENTS

Name of the student: Shishir Poudel

Residential Suburb and Postcode: 2077
Placements period (from-until) – 1-03-2021 ----- 22-03-2021
Please answer the following in Yes & No and add comments for answering Yes to any of the following questions.

Question Yes or No Comment

1. Have you got any cold/flu like symptoms? No
If yes, please specify.

2. In the past 14 days, have you travelled to No

anywhere?

3. In the past 14 days, have had any contact No

with confirmed COVID-19 case?

4. Have you travelled to Victoria or in close No

contact with someone from Victoria in
past 14 days?
5. Have you travelled any NSW COVID-19 No
affected Area recently?

6. Have you attended the list of venues given No

to you along with this declaration in the
last 14 days?

Signature: Shishir
Date: 24/02/2021