Please be aware that all Visitors must:

Complete this tool to ensure you are safe to visit.
We will confirm a suitable time for you to visit and carry out the necessary work/tasks intended.
Please be aware if deemed safe to visit a health declaration screening will be undertaken on the day of your visit. Evidence of flu vaccine remains a requirement to attend our site.

Business Name

Full Name *

First and Last Name

Telephone *

Reason for Visit: *

Proposed Date of Visit: *

Date

Signature *

Clear

Upload your Immunisation History Statement or COVID-19 Digital Certificate

1. Have you been fully vaccinated for COVID-19, or partially vaccinated and or booked to have Dose #1 or Dose #2? Or do you have a Medical Exemption? *

Yes No

2. I will/have provided evidence of the above prior to or when visiting *

Yes No

1. Do you understand the precautions you should be observing? such as:Avoiding people who have been overseas in the last 14 days, Avoiding people who have been isolated in the last 14 days, Avoiding people who have cough, cold or other respiratory symptoms or COVID symptoms, Maintaining social distancing of at least 1.5 meters, avoiding close contact and wearing a mask, Avoiding being in a large group, Abiding by the current state restrictions/rules *

Yes No

2. Are all people in your household or workplace healthy and/or social circle well? and Do you declare you are safe and healthy to visit? *

Yes No

3. Do you understand that you need to notify us if you become unwell after the visit? *

Yes No

4. Have you been exposed recently (last 14 days) to a suspect or positive case or been asked to self-quarantine or await a COVID test result? *

Yes No

5. Have you lived or visited or been in contact with any person or persons from a Public Exposed site in Victoria or Red/Orange zones from other states?(Please be aware that when travelling to Victoria from other states a Travel Permit is required or an exemption - please be prepared to offer any evidence to us when requested). *

Yes No

6. Do you work across multiple sites/organsations or visit other aged care homes/hospitals that have been exposed to COVID-19 cases? *

Yes No

7. Do you have a current Victorian Travel Permit as you are interstate? *

Yes Not Applicable

Q7 - Please list details

YOU ARE NOT SAFE TO VISIT

Mistake? Click here to Restart the Pre-Risk Tool

Risk Table *

	YES	NO
1. Do you (Visitor) - understand the precautions you should be observing? such as: You must be well to visit, Avoiding people who have been overseas in the last 14 days, Avoiding people who have been isolated in the last 14 days., Avoiding people who have cough, cold or other respiratory symptoms or COVID symptoms. , Maintaining social distancing of at least 1.5 meters, avoiding close contact and wearing a mask, Avoiding being in a large group, Abiding by the current state restrictions/rules.
2. Are all people in your household or workplace healthy and/or social circle well? and do you declare you are safe and healthy to visit?
3. Do you understand that you need to notify us if you become unwell after the visit?
4. Have you been exposed recently (last 14 days) to a suspect or positive case or been asked to self-quarantine or await a COVID test result?
5. Have you lived or visited or been in contact with any person or persons from a Public Exposed site in Victoria or Red/Orange zones from other states? (Please be aware that when travelling to Victoria from other states a Travel Permit is required or an exemption - please be prepared to offer any evidence to us when requested).
6. Do you work across multiple sites/organsations or visit other aged care homes/hospitals that have been exposed to COVID-19 cases?
7. Do you have a current Victorian Travel Permit as you are visiting from Interstate or been Interstate? (Please tick no, if not applicable)

If you answer NO to Question 1- 3 this means High Risk and No Entry.
If you answer YES to Question 4 - 6 this means High Risk and possible No Entry.

Pre-Site Visit Risk Tool

YOU ARE NOT SAFE TO VISIT

Mistake? Click here to Restart the Pre-Risk Tool