Fillable CLC COVID-19 Declaration - CLC-declaration-form post June 5

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CLC COVID-19 Declaration - CLC-declaration-form post June 5

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Country of origin: AUSTRALIA
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This declaration must be attached to all online permit applications or forwarded to
permits@clc.org.au
1
s
t
June 2020
P
age 1 of 2
COVID-19 Declaration for access to Aboriginal
Land/Communities
To minimise the transmission of pandemic disease during a public health threat all permit applicants must
declare all travel in the past 14 days as well as any current illness.
If any applicant has tested positive to Covid-19, are displaying symptoms or have travelled to a high-risk
region within the past 14 days they must cease travel to remote communities and any permit for travel is
invalidated.
Have you travelled outside of Australia (overseas) and or entered into the
Northern Territory (from overseas or interstate) in the last 14 days?
Yes ☐
No ☐
If you have ticked YES, provide details of travel below.
What towns or regions have you visited outside the Northern Territory
in the last 14 days?
Dates visited
(eg. 21/03/20 to
24/03/20)
This declaration must be attached to all online permit applications or forwarded to
permits@clc.org.au
1
s
t
June 2020
P
age 2 of 2
Are you applying for an exemption from border quarantine in order to directly
enter Aboriginal land after crossing the NT border?
Yes ☐ No ☐
If yes, you must provide evidence of your exemption quarantine conditions. CLC will assess these
before issuing a permit.
Mining Explorers and their contractors applying for permits will be subject to the condition that any
permittee must either have been situated continually within the NT for at least 14 days prior to entry on
Aboriginal land or, for any permittee entering from interstate, that they have undertaken monitored
quarantine for 14 days prior to entering aboriginal land, and display no symptoms of the COVID-19 virus.
Evidence of quarantine completion will need to be provided and should be emailed to
mining.admin@clc.org.au stating your permit application number in the subject line.
Do you have any of the following COVID-19 symptoms?
Cough ☐
Fever ☐
Cough without fever ☐
Sore throat ☐
Body aches, muscle or joint pain ☐
Lethargy ☐
Other (please specify)
☐
Declaration
I, hereby
declare that:
• I have accurately provided all travel and illness information required of me in regard to
the past 14 days
• I have not knowingly come into contact with positive cases of COVID-19
• If I travel outside the Northern Territory during the period of a valid permit, I must re-
submit an updated CLC COVID-19 Declaration to permits@clc.org.au
• If I have any of the symptoms listed above, my permit to Aboriginal land is invalidated.
• In the event of a positive test for COVID-19 my permit will be invalidated
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CLC COVID-19 Declaration - CLC-declaration-form post June 5

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Completed 3 July 2020

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