Secondary contact form

This form is intended to provide secondary contacts who are required to quarantine for 14 days under the Management of Secondary Contacts Direction with the documentation they may require for their employer or to support a claim for financial assistance with Services Australia. A secondary contact is a person who currently resides in the same residence as the close contact or who has resided in the residence since the time when the close contact exposure occurred.

Further information regarding eligibility for financial assistance and how to make a claim is available on the Services Australia website at: https://www.servicesaustralia.gov.au/individuals/subjects/getting-help-during-coronavirus-covid-19.

Privacy notice

Personal information is collected in this document by or for Queensland Health, which includes the Department of Health and the Hospital and Health Services, for the purpose of responding to a declared public health emergency under the Public Health Act 2005 and may be shared with other Queensland Government departments and agencies for that purpose. Queensland Health may use your personal information for the purposes of contact tracing, administering quarantine requirements, or for another purpose related to COVID-19.

All personal information will be handled in accordance with the Information Privacy Act 2009 (Qld). Personal information provided by you will be securely stored and only accessible by appropriately authorised officers. Personal information recorded in this document will not otherwise be disclosed to other parties without your consent, unless the disclosure is authorised or required by under law.

If you are providing personal information on behalf of another person, you are required to inform them of this privacy statement and that their personal information has been collected.

If only part of your personal information or no information is provided, then we may not be able to contact you and you, or the person who you have completed this form on behalf of, may not comply with your obligations under the Public Health Act 2005.

For information about how Queensland Health protects your personal information, or to learn about your right to access your own personal information, please see our website at https://www.health.qld.gov.au/global/privacy.

Required fields are marked with an asterisk (*).
Privacy Notice
I have read and understood the Privacy Notice *

Filling in form on behalf of another person
Are you filling this in on behalf of another person? *
Personal details (parent, legal guardian or power of attorney)
(Mobile preferred - Please enter numbers only, no spaces or non-numerical characters)
Personal details (secondary contact)
Date of birth *
(Mobile preferred - Please enter numbers only, no spaces or non-numerical characters)
(Street, suburb and postcode)
(Street, suburb and postcode)
(Street, suburb and postcode)
Are there other persons who usually reside at this address who are also considered secondary contacts?
Personal details (additional secondary contacts 1)
Date of birth
(Mobile preferred - Please enter numbers only, no spaces or non-numerical characters)
(Street, suburb and postcode)
Are there other persons who usually reside at this address who are also considered secondary contacts?
Personal details (additional secondary contacts 2)
Date of birth
(Mobile preferred - Please enter numbers only, no spaces or non-numerical characters)
(Street, suburb and postcode)
Are there other persons who usually reside at this address who are also considered secondary contacts?
Personal details (additional secondary contacts 3)
Date of birth
(Mobile preferred - Please enter numbers only, no spaces or non-numerical characters)
(Street, suburb and postcode)
Are there other persons who usually reside at this address who are also considered secondary contacts?
Personal details (additional secondary contacts 4)
Date of birth
(Mobile preferred - Please enter numbers only, no spaces or non-numerical characters)
(Street, suburb and postcode)
Are there other persons who usually reside at this address who are also considered secondary contacts?
Personal details (additional secondary contacts 5)
Date of birth
(Mobile preferred - Please enter numbers only, no spaces or non-numerical characters)
(Street, suburb and postcode)
Are there other persons who usually reside at this address who are also considered secondary contacts?
You are trying to list more than 5 additional secondary contacts. Please fill in the rest of this form, submit it first and then redo the form again but enter in the additional secondary contacts of the people that you did not include in the first submission.

Personal details (close contact)
Date of birth
(Mobile preferred - Please enter numbers only, no spaces or non-numerical characters)
(Street, suburb and postcode)
Declaration
Confirm *
Acknowledge *
By submitting this form, I declare that the information I have provided in this form is true and correct to the best of my knowledge. I acknowledge that knowingly providing false, misleading or incorrect information is an offence under the Public Health Act 2005 punishable by a fine of $4,135 or a court-imposed penalty of up to $13,785.

Unfortunately, we are unable to collect your information online. Please call 134 COVID (13 42 68) to provide your information over the phone or to have the Privacy Notice explained to you.

Last updated: 2 December 2021