Confirmed COVID-19 diagnosis reporting form

Full name of notifier (Duty holder)

Notifier (Duty holder) contact details

Impacted workplace

Workplace where impacted person was working during infectious period (if more than one workplace impacted please enter additional workplaces in the Additional workplaces box).

Only addresses from Victoria, Australia are accepted. Please use the following format. (Street number, Street name, Suburb, VIC, Australia.)

Enter any additional workplace addresses that are impacted (if relevant).

Full name of site representative

Complete this if the site representative is not the same person as the duty holder.

Enter the name(s) of the impacted person(s) and their shifts.