Coronavirus (COVID-19) Self Assessment Questionnaire Coronavirus COVID-19 Self-Screening Questionnaire Employee & Contractor Self-Assessment of Personal Risk and Health Status C.E.M. Alliance is committed to providing a safe workplace and reducing the risk of injury and harm to all employees, sub-contractors, clients, visitors and the general public and is following the development of the Coronavirus disease (COVID-19) closely. In the interest of maintaining a safe and healthy environment for everyone, we ask that you carefully complete this self-assessment in the following :- • New Employees or Subcontractors no more than 48 hours prior to attending any C.E.M. Alliance site or C.E.M. Alliance Client Site or Location • Existing employees or subcontractors who have travelled, had suspected or confirmed exposure or feel sick and want to know what to do specifically in relation to coming to work. IMPORTANT: Please do not use this form in the event of a Medical Emergency or to seek Medical Advice. Name* First Last Contact Phone Number*Email* Q1. Are you a Subcontractor?* Yes No Company* Company Department or Location* Dept / Location Q2. Have you recently travelled Interstate or Overseas?* Yes No Travelled To / From* Please type Australian State(s) or Country/Countries of travel in or through Dates of Travel* Please type dates of travel Q2(a): Is it less than 15 days since you arrived in Western Australia from an International or Interstate location?* Yes No You cannot attend a C.E.M. Alliance site or C.E.M. Alliance client site or location until 7 days have elapsed from the date you arrived back into Western Australia.Q3. Within the last 7 days, have you had Contact with anyone confirmed to have COVID-19?* Yes No Contact is defined as: A household member or intimate partner of a person with COVID-19 who has had contact with them during their infectious period; or Someone who has had close personal interaction with a person with COVID-19 during their infectious period: That have had at least 15 minutes face to face contact where a mask was not worn by the exposed person and the person with COVID-19; or Greater than two hours within a small room with a case during their infectious period, where masks have been removed for this period by the exposed person and the person with COVID-19 (note: others wearing masks in this scenario would not be a contact); or Someone who is directed by WA Health that they are a close contact.You cannot attend a C.E.M. Alliance site or C.E.M. Alliance client site or location. Q4. Do you have any flu-like symptoms such as a fever, cough, sore throat, nausea, vomiting or difficulty breathing?* Yes No You cannot attend a C.E.M. Alliance site or C.E.M. Alliance client site or location. If you have answered NO to all of the above questions no further action is required from you. If you have answered YES to ANY the above questions please contact our HR team on 08 9725 7372 to seek further direction. Consent* Declaration and Consent.I declare that I have completed the Coronavirus COVID-19 Self-Screening Questionnaire truthfully and to the best of my knowledge at the time of submission. I clearly understand that a false or misleading declaration may put other people's health at significant risk. I consent to the information provided above being released to any medical personnel, emergency services, receiving hospital and/or C.E.M. Alliance's Senior Management & Supervisors involved in my treatment, transport or recovery.Date* DD slash MM slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged. RESOURCING TO DELIVER SCOPE SAFELY
