Orica Form - SOTER International

SOTER INTERNATIONAL

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ORICA STAFF COVID FORM

Please input this date: 12/26/2021*

First Name *

Last Name *

Contact Number (example: 0412345678) *

Date of Birth *

Email Address *

Home Address *

Have you been directed to a period of isolation by a state health department as a result of being in close contact with someone with Coronavirus (COVID 19)?*

Yes

IMPORTANT!

If you answered YES to the above question you must not attend work until advised by the Department of Health that you are released from isolation or until your 14-day quarantine period is
complete.

Have you been diagnosed with COVID-19? *

Yes

Have you come into contact with a person who has a confirmed or suspected case of COVID-19 within the past 14 days?
Please visit the QLD Hotspot website to review:
qld.gov.au/health/conditions/health-alerts/coronavirus-covid-19/current-status/contact-tracing *

Yes

Are you experiencing any of the following? (Select at least one) *

Fever (If you have a thermometer, take your own temperature.)

Chills

Cough

Sore throat

Shortness of breath

Runny nose

Loss of sense of smell

Sneezing

None of the above

IMPORTANT!

If you have answered YES to any of the symptoms, alert the COVID ester.

I certify I am the person named on this form and all the above information is correct.*

Yes

About Us

SOTER believes that all emergency services, paid or volunteer medical responses should be standardised through a common set of emergency care guidelines and training. Tactical Emergency Casualty Care is an internationally accredited, purposely design shared capability that can fulfill this, across police, fire services and rescue and aid organisations.

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Maroochydore, 4558 AUSTRALIA
T: 1300 276 837
(1300 2SOTER)

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