Covid-19 Status and Declaration

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

Date:
Name:
Phone:
Email:

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

If you answer yes to any questions please do not enter the premises. Please discuss with staff if you wish to continue a visit. Staff are required to gain approval from a Team Leader or Senior Manager. We apologise for any inconvenience or delay and thank you for your assistance keeping 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:
Office Use Only: Should access / visit be approved?
Yes	they have ticked the ‘None of the above options apply to me’ box.
No	they have answered yes to a question or have a raised temperature
Staff Name:	Designation:
Staff Signature:	Date: