COVID-19

MNCLHD Assessment for New Employees

Name: Donna Hughes Stafflink ID: 51003292

Department: Emergency Dept Facility: PMBH

All new staff including new recruits, clinical personnel, volunteers and students to MNCLHD must answer the
below questions and submit this form for review. Any ‘YES’ responses must be reviewed by MNCLHD Infection
Control prior to commencing employment with MNCLHD. Should you have any questions regarding COVID-19
or this assessment please contact MNCLHD Infection Control on (02) 0419990693

1. Have you ever been diagnosed with COVID-19?

NO X

If yes: date when

2. Have you been in contact with / treated any person confirmed to have COVID-19 case and were not
wearing appropriate Personal Protective Equipment (PPE)? i.e. mask, gown, protective eyewear and
gloves, in the last 14 days, or been asked to self-isolate by a health official?
NO X

If yes: date when

3. Have you been to any of the locations or travelled on nominated public transport routes, during the
time and date indicated, in the “Close contacts – Get tested immediately and self-isolate for 14 days”
or “Casual contacts – Get tested immediately and self-isolate until you get a negative result”, or
“Monitor for symptoms”, or “Public transport routes” tables at NSW Health - Case locations and
alerts.? (you MUST Check this link before answering)
No X

If yes: Where:

Dates when:

4. Are you currently working or living in a location that has “stay at home orders” or from an area
currently in lock down? NO

If yes provide details of location you have been to and when (please include information on transport,
shops, stop overs & if mask were worn etc)

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5. Do you live with anyone who is a close contact of a COVID 19 case? NO X

6. Do you currently have a fever (including mild), cough, sore throat, shortness of breath, loss of taste,
smell or feel?
NO X

7. Have you ever been tested for COVID-19?

NO X

If yes: Where:

Date last tested & result

8. . Have you been fully immunised for COVID-19 (x2 injection)?

NO X

If yes: approximate date of 2nd dose of vaccine:

If No: have you had dose 1 of vaccine

YES X

if yes to 1 dose of vaccine approximate date due 2nd dose

12th July 2021

9. Have you had your 2021 influenza vaccine?

No X

If yes: approximate date of vaccine

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10. Have you undergone face to face training & assessment in the correct procedure for donning and
doffing PPE (including P2 fit checking) in line with NSW Health Infection Prevention & Control
application of PPE guideline

YES X

If yes: Where: PMBH

Date completed and signed off April 2020

11. Have you undergone fit test training in the use of P2 respirators?
NO X

If yes: Where:

Date of pass and signed off

Provide Respirator manufacture, model & size detail

If you have answered YES to Question 2 or 3 and are currently in the MNCLHD facility please advise your
assessing clinician, immediate supervisor, or hiring manager/recruiter immediately. The assessing clinician or
supervisor must give the employee a surgical mask to wear, take the employee to a single room, and call the
emergency department of the facility to discuss what to do next. MNCLHD Infection Control must be notified
as well.

If you have answered YES to Question 2 or 3 and are currently at home, please call Health Direct on 1800 022
222 to discuss what to do next. Please advise your supervisor or hiring manager/recruiter who will need to
advise MNCLHD Infection Control.

If you have answered YES to Questions 4 or 5 you must notify your immediate supervisor, hiring
manager/recruiter or assessing clinician. They then must notify MNCLHD Infection Control of the assessment
outcome. Further information will be required, and you may be excluded from clinical duties or your start
date may need to be delayed.

If you have answered YES to Questions 6 you MUST proceed directly to be COVID tested at your nearest
location

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MNCLHD Assessment for New Employees

Employee/Student Declaration:
I declare that the information and responses I have provided are correct and true. I have read and understand
the NSW Health COVID-19 Advice for healthcare workers, staff, healthcare students and volunteers in NSW
Health facilities information on the website and the NSW Infection Prevention & Control COVID19 Advice for
Health Workers.

X I have been given the opportunity to discuss any questions or concerns with the appointed facility clinician or
MNCLHD Infection Control.

X I agree to follow the recommendations of this document, the appointed facility clinician, MNCLHD Infection
Control or Public Health Unit with regards to working or placement in clinical areas of MNCLHD facilities.

X I understand that it is my responsibility to notify my manager immediately, and before my next shift, if I
have had, or believe I may have had, direct contact with a confirmed case of COVID-19.

X I understand I also must notify my manager if I have travelled to an area, which is known to have cases of the
COVID-19. I understand this will then allow a risk assessment for my suitability to attend the workplace.

Signature Donna Hughes Date 7th July 2021

Print Name Donna Hughes

This section to be completed by MNCLHD employer representative only

Further actions required Further actions taken

Completed form reviewed & actions approved by

Sign and print name

Date reviewed

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