Covid-19 Status and Declaration

Due to the status of COVID-19 (novel coronavirus) in Aotearoa New Zealand, we require all admissions to Stepping Stone Trust (SST) to complete this declaration, to prevent the spread of COVID-19 and other infections.

Date:
Name:
Phone:
Email:
Address:
Hoping for admission date:	Time:

Symptoms of COVID-19 include a runny nose, cough, sore throat, raised temperature, shortness of breath.

If you answer yes to any questions below, then your admission must be made with agreement by a senior member of SST. We apologise for any inconvenience or delay this may cause, and thank you for your assistance keeping all our tangata whai ora and staff safe and healthy.

In the last 14 days – have you:	Y / N:	Dates / Details:
Travelled outside the South Island or had close contact with someone who has
Had close contact with someone with symptoms or confirmed with COVID-19
Experienced any Flu-like symptoms
Had any other infectious issues
None of the above apply to me
Do you give consent to SST staff taking your temperature prior to entry	Temperature:

Covid-19 Vaccination status:	Y / N:	Dates / Details:
Have you received 1st vaccination
Have you received 1st and 2nd vaccination
Copy of your vaccination record
How can we help you achieve receiving full vaccination?
Declaration – All information provided on this form is true and accurate:
Your name:	Signature:
Referrer’s name (supporting you to complete this declaration:	Signature:

Office Use Only: Should admission be approved?
Yes	they have ticked the ‘None of the above options apply to me’ box.
No	they have answered yes to a question
Staff Name:	Designation:
Staff Signature:	Date: