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
Applicants 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I agree if this exemption is withdrawn I will immediately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
Applicants Signature
Applicants 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
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