Name *

First Name

Last Name

Are you currently required to be in self isolation? *

Yes

No

Were you at the rally in Sydney CBD on 21st August? *

Yes

No

Have you been in contact with someone who has been diagnosed with COVID-19 *

Yes

No

Have you recently or are you currently experiencing flu like symptoms *

Yes

No

Do you currently live in one of the 12 extended lockdown LGa's? *

Yes

No

Do you currently work in an extended lockdown LGA?

Yes

No