Volunteer Self Assessment for Risk of Coronavirus (COVID-19)

Volunteer name*
First Last
Recipient Name*
First Last
Staff name*
First Last
Have you been in close contact with a confirmed case of COVID-19 in the last 14 days?*
Have you returned home from overseas in the last 14 days?*
Are you experiencing fever or respiratory symptoms? (Do NOT visit if any symptoms or unwell, even if mild)*
Do you agree to wear a mask at all times if and as required by DHHS?*
Do you agree wash hands and sanitise regularly?*
Do you agree to let us know if you or anyone is unwell?*
Do you agree to practice social distancing by remaining 1.5 metres apart?*
Do you agree that you will maintain a record of date/time/location of recipients visited and inform library staff for COVID tracing purposes?*
Do you agree to arrange to meet at the front of the premises where possible?*
We understand that some recipients will require assistance from their voluteers to collect library materials
Estimated time of visit*
Acknowledgement*
I acknowledge I understand my responsibilities and will abide by my responses above