UoM COVID-19 Health Declaration Form

This checklist MUST be complete to submit this form. *

To be eligible to attend campus, you must answer NO to the following 4 questions:

Are you currently required to self-quarantine or self-isolate? *

You are currently required to self-quarantine (self-isolate)

Have you been tested for COVID-19 and are waiting for a test result? *

If you have been tested for COVID-19 and are still awaiting your test results, you should be in self-quarantine (self-isolating)

Have you been in close contact with a confirmed case of COVID-19? * (excluding contact required as a health care worker in a health care setting with full personal protective equipment)

If you have been in close contact with a confirmed case of COVID-19, you should be in self-quarantine (self-isolating) for a period of 14 days.

Are you currently experiencing ANY of the following symptoms? *

Fever
Sore throat
Cough
Shortness of breath, other respiratory symptoms
Feeling run down/fatigue

If you are reporting any of the following symptoms:

Fever

Sore throat

Cough

Shortness of breath, other respiratory symptoms

Feeling run down/fatigue

You MUST NOT attend any University of Melbourne campus.

You should self-isolate immediately and contact the Coronavirus Hotline on 1800 675 398 as per the Department of Health and Human Services Coronavirus website.

Part 2: Ongoing commitment to health and wellbeing

To be eligible to attend campus, you must agree and undertake all of the following:

I agree that every day I intend to come to campus:

I will review my answers to the four health check questions, and NOT come to campus if I answer yes to any of them
I will decide to stay home if I am feeling unwell with fever, chill or sweats, cough, sore throat, shortness of breath, runny nose, loss of sense of smell or feel generally unwell
By using public transport, I will plan my trip and consult advice produced by Public Transport Victoria (PTV) and abide by the physical distancing and hygiene measures suggested by PTV

* TICK THIS BOX TO AGREE!

I agree that whilst on campus I will:

Maintain physical distancing by keeping at least 1.5m between myself and others and follow room capacity instructions (to allow for 4 square metres of space per person in enclosed spaces)
Maintain hand hygiene, washing/sanitizing my hands regularly
Use good cough and sneeze hygiene (into a tissue with safe tissue disposal and washing hands or into my elbow)
Minimise the time I spend on campus and my movement around campus (limiting the number of buildings I visit)
When asked, agree to a temperature check to gain access to the building
Record places I’ve been on campus and people I encounter (The University strongly recommends downloading the COVIDSafe App and keeping a diary to assist with contact tracing)
use the Snap Send Solve app to let the University know of any feedback or concerns I may have to keep our Campus COVIDSafe (See, Say, Act)

* TICK THIS BOX TO AGREE!

I agree that if I become unwell whilst on campus, or think I might have COVID-19 related symptoms I will:

Leave the campus immediately
Seek medical advice and get tested for COVID-19 (available at the University Health Service)
- You can call the health service on 03 8344 6905 for advice and to book COVID-19 testing on your way home
Notify my supervisor / course coordinator and email campus-community@unimelb.edu.au

* TICK THIS BOX TO AGREE!

PLEASE DO NOT COME ONTO CAMPUS.

The health and safety of students, staff and the University community remain our top priority.

You have answered ‘Yes’ to one of the following questions:

Are you currently required to self-quarantine?
Have you been tested for COVID-19 and are waiting for a test result?
Have you been in close contact with a confirmed case of COVID-19? (excluding contact required as a health care worker in a health care setting with full personal protective equipment)
Are you are unwell with a new illness, and are currently experiencing any of the following symptoms: fever, chills or sweats, cough, sore throat, shortness of breath, runny nose, loss of sense of smell or feel generally unwell

Based on the information you provided, the current advice based on guidance from the Commonwealth Department of Health and Victorian Department of Health and Human Services’ as well as the Vice Chancellor’s Expert Scientific Advisory Panel is that you should not come onto campus for any reason.

Please notify your supervisor / course coordinator and campus-community@unimelb.edu.au about your situation and refer to https://www.unimelb.edu.au/coronavirus for more information

For more information or general questions:

Visit https://www.unimelb.edu.au/coronavirus
Email corona-virus-enquiries@unimelb.edu.au

For health or COVID test related questions/notification:

Call University Health Service COVID-19 Testing Hotline 03 8344 6905
Email campus-community@unimelb.edu.au

In order to be eligible to attend campus, you will need to recomplete the health declaration when your situation changes so that you answer NO to all four questions.

YOU ARE NOW ELIGIBLE TO COME ONTO CAMPUS

Thank you for agreeing to abide by the health, hygiene and physical distancing measures required to contain the spread of COVID-19 in our community – every time you attend campus. It is important that we all need to stay home if unwell and not attend campus.
What we do now becomes what happens next.
For more information or general questions:

Visit https://www.unimelb.edu.au/coronavirus
Email corona-virus-enquiries@unimelb.edu.au

For health or COVID test related questions/notification:

Call University Health Service COVID-19 Testing Hotline 03 8344 6905
Email campus-community@unimelb.edu.au

* TICK THIS BOX TO AGREE! By ticking the box you confirm that the answers above are true and accurate at the time of submission and that you acknowledge the above requirements.

Privacy Collection Notice

The University of Melbourne is committed to protecting your privacy in accordance with its responsibilities under applicable privacy laws. For further details see our privacy collection notice
By submitting any personal information in this questionnaire you consent to it being collected by the University of Melbourne for the purposes described in the privacy collection notice. * I have read and agree to the collection notice.

COVID-19 Health Declaration Form

Part 1: Health Check Questions

You are currently required to self-quarantine (self-isolate)

If you have been tested for COVID-19 and are still awaiting your test results, you should be in self-quarantine (self-isolating)

If you have been in close contact with a confirmed case of COVID-19, you should be in self-quarantine (self-isolating) for a period of 14 days.

If you are reporting any of the following symptoms: Fever Sore throat Cough Shortness of breath, other respiratory symptoms Feeling run down/fatigue

You MUST NOT attend any University of Melbourne campus.

Part 2: Ongoing commitment to health and wellbeing

To be eligible to attend campus, you must agree and undertake all of the following:

PLEASE DO NOT COME ONTO CAMPUS.

The health and safety of students, staff and the University community remain our top priority.

Based on the information you provided, the current advice based on guidance from the Commonwealth Department of Health and Victorian Department of Health and Human Services’ as well as the Vice Chancellor’s Expert Scientific Advisory Panel is that you should not come onto campus for any reason.

Please notify your supervisor / course coordinator and campus-community@unimelb.edu.au about your situation and refer to https://www.unimelb.edu.au/coronavirus for more information

If you are reporting any of the following symptoms:

Fever

Sore throat

Cough

Shortness of breath, other respiratory symptoms

Feeling run down/fatigue