image Date & Time of form completion: Name: Mobile: YOU MUST ANSWER ALL QUESTIONS Are you currently required to be in isolation because you have been diagnosed with coronavirus (COVID-19)? Yes No Have you been directed to a period of 14-day quarantine by DHHS as a result of being a close contact of someone with coronavirus (COVID-19)? Yes No If you answered YES to either of the above questions you should not leave your house until advised by DHHS that you are released from isolation or until your 14-day quarantine period is complete. You may NOT enter Omski Lodge. If you answered NO to the above questions, proceed to the symptom checklist below. Fever (If you have a thermometer, take your own temperature). You are considered to have a fever if above 37.5C. Yes No ARE YOU EXPERIENCING ANY OF THESE SYMPTONS? Chills Yes No Please advise temp, at time of filling in the form:

• This form must be submitted to by 5.00pm the day before your arrival at Omski for each separate visit

• An individual form must be completed by each visitor from each booking including children

• Failure to submit forms for all members and their guests of a booking by 5.00pm the day before arrival will result in cancellation of the booking and all parties being denied entry to Omski Lodge.

OMSKI COVID DECLARATION Cough Yes No Sore Throat Yes No Shortness of breath Yes No Runny nose Yes No Loss of sense of smell Yes No If you answered YES to any of the above questions. If you answered NO to all questions, you may travel to Omski. If you develop any of these symptoms whilst staying at Omski, you must advise the Lodge Captain and/or Lodge Manager and immediately leave Omski. PLEASE ACKNOWLEDGE THE FOLLOWING I will adhere to all Omski Covid Procedures and social distancing Yes No I will self-temperature test and record on a daily basis (Omski has a Thermometer) Yes No I have downloaded the CovidSafe App Yes No If you develop symptoms, stay at home and seek further advice from the 24-hour coronavirus hotline 1800 675 398 or from your general practitioner. By submitting this health certification, I acknowledge that shared accommodation at Omski Lodge may increase the risk of getting Covid-19. I understand and acknowledge this risk and I shall not hold Omski Ltd ABN 49 004 868 517, or the Volunteer Omski Ltd Committee liable. Parents please submit a certification for each of your children under 18. NAME: You may NOT enter Omski Lodge.
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