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Enrolled Nurse Professional Association NSW

Lighting The Way

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Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

Phone

My body temperature is lower than 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat, Shortness of breath,

I haven’t been in close contact with Covid-19 in the last 14 days

I declare that the information I’ve provided is accurate & complete

I agree to the information provided above, to being shared with relavent authorities for the purpose of contact tracing

Date

Thanks for submitting!

© 2020 by Enrolled Nurse Professional Association (NSW). ENPA NSW

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