GLA - Contact Tracing - Venues and Facilities

We all need to follow the COVID Safe measures put in place by the Queensland Government.

Please complete this form as a record of your visit to our venue/facility today.

Privacy Statement: Gladstone Regional Council is collecting your personal information for the purposes of COVID-19 contact tracing. Your information will only be accessed by authorised Council employees and may be released to State and Federal Health Authorities and public health officials. Your information will not be given to any other person or agency unless you have given us permission or we are required by law. This document is subject to the provisions of the Information Privacy Act 2009, Right to Information Act 2009 and the Public Records Act 2002.

I confirm that everyone listed on this form haven't returned from overseas or a COVID-19 hotspot in the last 14 days, I/we do not have cold or flu like symptoms and haven’t been in contact with a confirmed case of COVID-19 in the last 14 days. (Required)

Yes - I confirm No overseas travel, no COVID-19 hotspots visited, no symptoms, no contact

No - can't confirm as I/we answer yes to one or more items in the question.

First Name (Required)

Last Name (Required)

Phone (Required)

Email (Required)

Venue or Facility Visited Today (Required)

Check in additional family members

Actions
Click 'Add additional names' to start completing this question

How to submit the form

To submit the form details to us:

Complete the reCAPTCHA box.
Click 'Next' to review the details that you have provided.
Click on the blue 'Submit' button on the next page.

By completing this form I have read and agree to the use of my information in accordance with the Privacy Statement.

Visitor information

How to submit the form