Fillable Individual Quarantine Exemption Application (COVID-19)

Fill Online, Printable, Fillable, Blank Individual Quarantine Exemption Application (COVID-19) Form

Use Fill to complete blank online TAS.GOV.AU pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Individual Quarantine Exemption Application (COVID-19)

On average this form takes 9 minutes to complete

The Individual Quarantine Exemption Application (COVID-19) form is 2 pages long and contains:

  • 2 signatures
  • 8 check-boxes
  • 25 other fields

Country of origin: AUSTRALIA
File type: PDF

Australia forms for tas.gov.au

BROWSE TAS.GOV.AU FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
For more information visit
www.health.tas.gov.au/coronavirus
Version 1.0 | 22 March 2020
Individual Quarantine Exemption
Application (Health Service)
Email
Telephone 1 (Home)
Telephone 2 (Business)
Telephone 3 (Mobile)
Addresses for all states in the last 14 days:
All Health Facilities worked in during the past 21 days:
Travelling from information
Destination information
Applicant’s Signature
Family name
State
Name of Health Facility:
Arrival purpose and date due to commence role and employer (please be specic):
Name of Health Facility
State
Name of Health Facility
Title
Postcode
Date
Postcode
Postcode
Postcode
Applicant’s details
Given name/s
P2 | Tasmanian Government COVID-19 Response
Have you arrived from overseas within the last 14 days?
Authorising Ocer’s details
Do you display any inuenza like symptoms?
I will comply with any condition imposed on me.
I agree if this exemption is withdrawn I will immediately
self-quarantine for 14 days
Individual’s declaration
Authorisation
For more information visit
www.health.tas.gov.au/coronavirus
Privacy Statement The Department of Health collects personal information provided in this form for the purposes of processing your
application for assessed disclosure under the Right to Information Act 2009. Personal information will be managed in accordance with the
Personal Information Protection Act 2004 and may be accessed by the individual to whom it relates on request to the Department
Applicant’s Signature
Applicant’s Signature
Approved Not Approved
Date
Date
Yes
Yes
Yes
Yes
No
No
No
No
Name
Position
click to sign
signature
click to edit
dd mmm yyyy
click to sign
signature
click to edit
dd mmm yyyy
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Individual Quarantine Exemption Application (COVID-19)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 29 March 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document