Daily WORK CONTACT Declaration

Daily WORK CONTACT Declaration
Employee ID number*
if you are a visitor please put a 'V' otherwise your man number/id
Your Name*

First NameLast Name
Department*
Today's Date

DayMonthYearHourMinutesAM/PM Option
Have you operated or been a passenger in any plant, equipment or light vehicles (Equipment) during the shift/workday?*

YesNo
Equipment 01
Equipment 02
Equipment 03
Equipment 04
Equipment 05
Equipment 06
Have you had WORK CONTACT with another person during the shift/workday?*

YesNo
REGARDLESS of whether FACEMASKS are worn, the definitions of a WORK CONTACT include:

·       Persons you have spent greater than 10 minutes within 1.5m of during the course of a shift or day.

·       Persons you have spent greater than 10 minutes with in shared/open plan office space.

·       Persons you had crib with.

·       Persons you travelled in a vehicle with.

·       Persons you charged a face with.

·       Persons you offsided.

·       Persons you work alongside of.
Close Contact 01
Close Contact 02
Close Contact 03
Close Contact 04
Close Contact 05
Close Contact 06
Close Contact 07
Close Contact 08
Close Contact 09
Close Contact 10
Close Contact 11
Close Contact 12
Close Contact 13
Close Contact 14
Close Contact 15
Close Contact 16
Close Contact 17
Close Contact 18
Close Contact 19
Close Contact 20
I declare the above to be true and correct.*

Yes.
Should be Empty: