University of Melbourne COVID-19 case & contact survey

Privacy collection information

Responses to this form are being collected by the University of Melbourne's Public Health Network to enable a rapid public health response to COVID-19.

Please use this form to report all COVID-19 cases and contacts within the University of Melbourne community.

If you have any questions, please email the Public Health Network at
public-health-network@unimelb.edu.au

All information gathered in this form will be managed in line with the University's COVID-19 Privacy Collection Notice.

I consent to the University of Melbourne collecting and processing my personal information for the purpose of preventing and managing the risk of COVID-19 transmission and to ensure compliance with any public health directions which may apply to the University, as described in the COVID-19 Privacy Collection Notice provided.

I confirm that I have read and understood the COVID-19 Privacy Collection Notice

What is your reason for completing this form?

Reporting myself as a positive COVID-19 caseReporting myself as a close contact (including household contacts)

Your information

I am a...
(If you are both staff and a student please select staff)

StaffStudentContractorOther

Please state why you selected Other

First name

Family name

Date of birth (dd/mm/yyyy)

Phone

University of Melbourne email address

Student/Staff ID number

Email address

Contracting agency name

Contractor ID

Close contact details

What date did your close contact period start? (dd/mm/yyyy)

For further information about the rules for close contacts please review government guidance

COVID-19 test details

What type of COVID-19 test was performed?

Rapid antigen test (RAT)PCR test

What date did you test positive for COVID-19? (dd/mm/yyyy)

Medical treatments, also known as early therapies or antivirals, are available for eligible people to prevent them from getting so sick that they need to go to hospital. These treatments must be taken as soon as possible after COVID-19 symptoms begin and can be lifesaving. More information about these medicines is available here.

Additional information

Do you work, undertake research, study or live in any of the following settings?

Student accommodation or residential collegesHospitals or clinical settings University childcare centres

No

Student accommodation setting

Please select which student accommodation setting you live/work/study in:

Accommodation

Other student accommodation details

Do you share a bedroom (a common sleeping room) with anyone?

YesNo

Please list the name, email and phone number of each person you share a room with. If they are a University of Melbourne student or staff member, please include their University email address

I acknowledge that I must inform my accommodation manager that I have tested positive for COVID-19

Health or clinical setting

Please indicate which hospital or clinical setting(s) you work or study in:

Childcare setting

Please select which childcare centre(s) you work or study in:

Swanston Children's CentreQueensberry Children's CentreEarly Learning Centre

Your University attendance

Were you on campus, at a University event, or on a University field trip within the 48 hours prior to your first symptoms or positive test?

YesNo

Where have you been

Please provide details of where you attended within the 48 hours prior to your first symptoms or positive test

Attendance details

What was the date? (dd/mm/yyyy)

Why were you there?

Other attendance reason

Location details

See maps.unimelb.edu.au for guidance

Building name or building number

Floor

Room number or room name

Start time

End time

Class details

View MyTimetable or your subject’s Timetable tab in the University Handbook for guidance in completing the following information

Subject code

Class description

e.g. Lecture 1, Tutorial 3

Event details

Event name

Event organiser name (if known)

Event organiser email (if known)

I am aware that I need to inform the event organiser that I have tested positive for COVID-19

Confirmation

I can confirm the information I have provided is complete, true and correct

Hpot