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COVID-19 Staff Triage Form

Sunnyfield Staff Members

Complete this form if you have tested positive for COVID-19, have been exposed to a positive COVID-19 case, or displaying COVID-19 symptoms.

NSW Health COVID-19

ACT Health COVID-19

Click the NSW or ACT Health button to find out the latest COVID-19 information.

COVID-19 Staff Triage Questionnaire

"*" indicates required fields

Email

Staff member's name*

As stated on Medicare Card or Driver’s License

First Middle Last

Mobile number*

Vaccination status*

Service questions

Sunnyfield Division*

Name of the Sunnyfield service you work at*

Do you work across multiple services?*

Yes

No

Your Manager's name*

First Last

What date were you last at a Sunnyfield service?*

In the last 72 hours what times were you in a Sunnyfield service?*

When is your next shift scheduled?*

COVID positive

Have you tested COVID positive?*

Yes

No

What date were you tested?*

Upload your PCR or RAT test results*

If you have tested positive for COVID. You must upload evidence of the RAT or PCR in order to submit this form to the PRG.

Max. file size: 4 MB.

COVID symptoms

Do you have COVID symptoms?*

Yes

No

When did you start showing symptoms?*

If yes please select*

Runny nose

Cough

Fatigue

Fever (temperature above 37.5▫C)

Sore throat

Loss of taste or smell

Shortness of breath

Headache

Have you had a COVID test?*

Yes

No

What date were you tested?

MM slash DD slash YYYY

Upload your PCR or RAT test results

Max. file size: 4 MB.

COVID exposure

Have you been exposed to a positive COVID case?*

Yes

No

Have you had a COVID test?

Yes

No

What date were you tested?

MM slash DD slash YYYY

Upload your PCR or RAT test results

Max. file size: 4 MB.

Living with a positive COVID case

Do you live with a positive COVID case?*

Yes

No

What date did the person you live with test positive for COVID-19?*

Have you had a COVID test?*

Yes

No

What date were you tested?

MM slash DD slash YYYY

Upload your PCR or RAT test results

Max. file size: 4 MB.

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1300 588 688
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PO Box 193 Frenchs Forest NSW 1640

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ABN 72 000 415 127
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Charity Fundraising Number 13915
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© 2024 Sunnyfield

<img loading="lazy" decoding="async" width="135" height="195" src="https://www.sunnyfield.org.au/wp-content/uploads/sunnyfield-disability-services-logo.png" alt="" title="" class="wp-image-468" />

ABN 72 000 415 127
ISO 9001: 2015 Quality Management System
Charity Fundraising Number 13915
Privacy Policy
Sitemap
Terms & Conditions
© 2024 Sunnyfield

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