Visitor Coronavirus (COVID-19) Self-Assessment Form "*" indicates required fieldsIs your intended site visit essential? Please complete this information 24hrs prior to your visit.Nature of Visit & Area/location of visit:*Are you, or anyone you live with, currently experiencing any cold or flu-like symptoms?*(Including but not limited to fever, dry cough, fatigue, sore throat, loss of taste and/or smell, runny nose, respiratory illness, or difficulty breathing.) Yes NoHave you had close contact with someone diagnosed with COVID-19 within the last 14 days?* Yes NoHave you returned from overseas in the past 14 days?* Yes NoHave you travelled from a COVID location in the last 14 days?* Yes NoPlease indicate where and when:*If you have visited any of the https://www.nsw.gov.au/covid-19 locations detailed by NSW Health, you will not be permitted entry to the Mount Pleasant Operation.I acknowledge and understand: - the contagious nature of COVID-19 and that NSW Health recommend practicing physical distancing. - MACH Energy has put preventative measures in place to reduce the spread of COVID-19, however, it is impossible for MACH Energy to prevent all risk of infection and it cannot guarantee that I will not become infected with COVID-19. - my visit may take place in close proximity to MACH Energy staff. This will potentially expose me to respiratory droplets, which may spread COVID-19. - I may be required to wear a mask that covers my mouth and nose during my visit. - the contagious nature of COVID-19 and I voluntarily assume full responsibility for the risk that I may be exposed to (or infected by) COVID-19 and that such exposure or infection may result in personal injury, illness, permanent disability and/or death. - that by signing this Form I release, covenant not to sue, discharge, and hold harmless MACH Energy, its employees, agents, and representatives from any claim, including all liability, claims, actions, damages, costs, or expenses of any kind arising out of or relating to my visit. By submitting this Form to MACH Energy, you indicated your acceptance of the above.Date of Site Visit:* DD slash MM slash YYYY Expected arrival time:* HH: MM AMPM AM/PMName* First Last Email* Today's Date:* DD slash MM slash YYYY Mobile Phone Number*Your Company:*MACH Energy Rep:*Note: All visitors to MACH Energy Mount Pleasant Operation are required to complete this form under Part 3 of the NSW Public Health (COVID-19 Restrictions on Gathering and Movement) Order (No 7) 2020 Records and exchanges of information. The information provided will be managed in accordance with MACH Energy’s Company Privacy Policy kept securely on MACH’s Record Management System for at least a period of four weeks. Where requested, information will be provided to the Chief Health Officer.EmailThis field is for validation purposes and should be left unchanged.