Return to work - moderate or high risk exposures

Symptom Assessment Form
The Symptom Assessment Form is part of the return to work program for high or moderate risk exposures. This form is to be completed by the Manager with the staff member.

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

Symptom Assessment Form

"*" indicates required fields

Please select Sunnyfield Service*
Manager's Name*

Essential Worker Information

Staff Member's Name*

Questions for the staff member who was a moderate or high risk exposure

Did you complete a day-6 RAT or PCR test?*
What date did you complete the day-6 test?*
What was the result?*
Do you have a sore throat?*
Do you have a runny nose?*
Do you have a cough?*
Are you suffering from shortness of breath?*
Max. file size: 128 MB.
Date of return to work*

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