Personal Declaration

I sincerely declare I am currently well and have no symptoms including a runny nose, sore throat, cough or fever.

I have been in New Zealand for more than 14 days and am not required to self‐isolate.
I have not been in contact with anyone who has recently returned or travelled from overseas.
No member of my family, someone I live with or any close friend(s) have recently returned or travelled from overseas except for countries noted above.
Further I declare that to the best of my knowledge I have not been in contact with any person known to be infected with the COVID‐19 virus.
Should I become ill in the next 14 days I will advise Punchbowl and follow all New Zealand Health Department guidelines regarding self‐isolation.

While on site I will always adhere to the following best practise hygiene measures:

Avoid close contact with people with cold or flu‐like illnesses.
Cover coughs and sneezes with disposable tissues or clothing, i.e. the crock of the elbow.
Wash hands for at least 20 seconds with soap and hot water, dry them thoroughly and use sanitiser dispensers where provided:
- Before entering the packhouse or orchard
- When entering the kitchen areas
- Before handling fruit – in the packhouse and orchards
- before eating or handling food
- after using the toilet
- after coughing, sneezing, blowing your nose or wiping children’s noses or after caring for sick people
If you develop a fever (over 38 degrees), and a cough, or difficulty breathing, or a sore throat (flu‐like symptoms) you should call Healthline’s dedicated COVID‐19 number 0800 358 5453.
General information is available on the Ministry of Health website: COVID‐19 (novel coronavirus). https://www.health.govt.nz/

Details of allergies/medication/aliments/existing medical conditions

Name*

First Last

Phone

Email*

Date of Birth

Mode of transport to work*

Names of others who share transport*

Declaration*

Read each statement carefully and then tick the applicable box for each

I do not have any underlying health issue that makes me more vulnerable to COVID-19. These issues include COPD (Chronic Obstructive Pulmonary Disease), heart conditions, high blood pressure, kidney problems, diabetes, cancer or undergoing cancer treatment, compromised immune system.
I am well. I am symptom free. I will immediately report the onset of any symptom to my supervisor at any time during or outside of work.
At work I will maintain a minimum of 1.5 meters distance from others at all times including during breaks.
I can confirm I have read and understood the requirements of the KIWIFRUIT ORCHARD PROTOCOL FOR MINIMISING SPREAD OF COVID-19.
If I am a critical worker, I will travel direct between my stated home address and essential work in accordance with Government requirements.
I confirm that I understand and will adhere to the New Zealand Government Covid-19 Rules
I will wear a mask at all times while at work.
I understand and consent to having my temperature taken and recorded before each shift

Consent*

I certify that the information provided is correct and no relevant material/information has been omitted. I understand that this information will be used for the purposes of ensuring safety on site including compliance with other agencies and that any incorrect or misleading or important information that has been omitted may disqualify me from entering site and termination of contract.

I consent to Punchbowl providing information to Government Agencies where required.

I declare that I have completed all sections of this truthfully and shall inform Punchbowl PackCo of any change in my circumstances that affect the answers given above.

I Agree

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Personal Declaration