Declaration of Fitness to Return to Work / Study:
Covid-19 2020
WHS-PRO-FORM-006f
Version: 1.0 Approval Date: 25/03/2020 Next Review Date: 25/03/2021 Page 1 of 1
Declaration
Please note that you must complete the declaration set out below.
I, __________________________________________________________________________ [full name], of
____________________________________________________________________________ [address], in the
State of ___________________________________________ [state] make the following declaration:
• I declare that the information provided in connection with this declaration is true and complete;
• I declare that I was directed by the Queensland Public Health Unit (or other medical provider) to self-
quarantine due to travel requirements; suspected coronavirus diagnosis; close contact of a positive Covid-19
case; or had a positive diagnosis of Covid-19;
• I declare that my 14 day period of quarantine / isolation has passed;
• I declare that following a diagnosis of Covid-19 that at least ten (10) days have passed since the onset of my
symptoms; and that all symptoms of my acute illness has been resolved for the previous 72 hours.
I believe that the statements in this declaration are true in every particular.
Signature of Applicant ________________________________ Date ___________________________________
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