Interstate Hotspot Self-Declaration Form: Record ID
Are you a current ACT resident?* must provide value
Yes
No
Please provide proof of residency in the ACT.* must provide value
HIDDEN: Please tick yes to unhide the fields on this form for non-ACT residents.
This is to ensure that historic data for non-ACT residents is retained.
Yes
No
Which State or Territory are you travelling from?* must provide value
NSW
VIC
QLD
SA
TAS
WA
NT
ACT Public Health Directions require people who have visited the following affected locations to quarantine until 14 days after leaving the affected areas:
The following Local Government Areas (LGAs) Blacktown City local government area Burwood local government area Canada Bay City local government area Canterbury-Bankstown local government area Cumberland local government area Fairfield City local government area Inner West local government area Liverpool City local government area Parramatta City local government area Strathfield Municipality local government area A venue, location or public transport route at the same time as a confirmed case, as identified by NSW Health . Please refer to the NSW Health website for up to date information about affected venues, locations, and transport routes. It is your responsibility to stay up to date with evolving areas of concern.
ACT Public Health Directions require people who have visited the following affected locations to quarantine until 14 days after leaving the affected areas:
Greater Brisbane, on or after 2 January 2021. This includes the Brisbane, Moreton Bay, Ipswich, Redlands and Logan Local Government Areas. Persons currently in these areas should not be travelling. The list of areas and current restrictions can be found on the Queensland Health website .
Â
ACT Health's advice is that you do not travel to the ACT at this time.
It is everyone's responsibility to follow the health advice and do what we can to ensure we keep ourselves and the community safe.Â
If you still intend on travelling to the ACT today, please complete the Exemptions form . Please note that if you are required to quarantine in the ACT, the entire household that you are staying with are also required to quarantine.
ACT Health requires you to apply for an Exemption. You will not be allowed to enter the ACT without an approval for Exemption.
Please complete and submit the Exemption Form using the following link
Â
HIDDEN - Registration Date/Time* must provide value
Now D-M-Y H:M:S
HIDDEN: Have you visited an affected location? Please refer to the blue box above.
For more detailed information on affected locations, please use the following link.
* must provide value
Yes
No
Have you visited any of the following affected locations?
For more detailed information on COVID-19 affected areas, please use the following link .
For more information on identified venues, locations or public transport routes in NSW, please use the following link .
Have you visited any of the following affected locations in Queensland?
For more detailed information on COVID-19 affected areas, please use the following link .
Â
Have you visited any of the following affected locations in Victoria?
For more detailed information on COVID-19 affected areas, please use the following link .
Â
Have you visited any of the following affected locations in South Australia?
For more detailed information on COVID-19 affected areas, please use the following link .
Â
Have you visited any of the following affected locations in Tasmania?
For more detailed information on COVID-19 affected areas, please use the following link .
Â
Have you visited any of the following affected locations in Western Australia?
For more detailed information on COVID-19 affected areas, please use the following link .
Â
Have you visited any of the following affected locations in Western Australia?
For more detailed information on COVID-19 affected areas, please use the following link .
Â
Have you visited any of the following affected locations?
For more detailed information on COVID-19 affected areas, please use the link above.
For more information on identified venues, locations or public transport routes in NSW, please use the link above.
The Northern Beaches LGA, on or after 11 December 2020.
Greater Sydney (including Central Coast, Blue Mountains and Wollongong), on or after 21 December 2020
Cumberland LGA
A venue, location or public transport route at the same time as a confirmed case
Have you visited any of the following affected locations?
For more detailed information on COVID-19 affected areas, please use the link above.
Â
Â
Greater Brisbane (including Logan, Ipswhich, Redlands, Brisbane or Moreton Bay), on or after 2 January 2021
A venue, location or public transport route at the same time as a confirmed case
Have you visited any of the following affected locations?
For more detailed information on COVID-19 affected areas, please use the link above.
Â
Â
* must provide value
Victorian Locations
A venue, location or public transport route at the same time as a confirmed case
Have you visited any of the following affected locations?
For more detailed information on COVID-19 affected areas, please use the link above.
Â
Â
* must provide value
SA Locations
A venue, location or public transport route at the same time as a confirmed case
Have you visited any of the following affected locations?
For more detailed information on COVID-19 affected areas, please use the link above.
Â
Â
* must provide value
Tas Locations
A venue, location or public transport route at the same time as a confirmed case
Have you visited any of the following affected locations?
For more detailed information on COVID-19 affected areas, please use the link above.
Â
Â
* must provide value
WA Locations
A venue, location or public transport route at the same time as a confirmed case
Have you visited any of the following affected locations?
For more detailed information on COVID-19 affected areas, please use the link above.
Â
Â
* must provide value
TAS Locations
A venue, location or public transport route at the same time as a confirmed case
None of the above
None of the above
* must provide value
None of the above
* must provide value
None of the above
* must provide value
None of the above
* must provide value
None of the above
* must provide value
None of the above
Which affected locations have you spent the most time in? Blacktown City local government area, New South Wales Burwood local government area, New South Wales Canada Bay City local government area, New South Wales Canterbury-Bankstown local government area, New South Wales Cumberland local government area, New South Wales Fairfield City local government area, New South Wales Inner West local government area, New South Wales Liverpool City local government area, New South Wales Parramatta City local government area, New South Wales Strathfield Municipality local government area, New South Wales
Which of the following LGAs have you spent time in the past 14 days?* must provide value
Northern Beaches local government area, New South Wales
Bayside local government area, New South Wales (excluding transit through Sydney airport)
Blacktown City local government area, New South Wales
Blue Mountains City local government area, New South Wales
Burwood local government area, New South Wales
Camden local government area, New South Wales
Campbelltown City local government area, New South Wales
Canada Bay City local government area, New South Wales
Canterbury-Bankstown local government area, New South Wales
Central Coast local government area, New South Wales
Cumberland local government area, New South Wales
Fairfield City local government area, New South Wales
Georges River local government area, New South Wales
Hawkesbury City local government area, New South Wales
Hornsby Shire local government area, New South Wales
Hunter's Hill Municipality local government area, New South Wales
Inner West local government area, New South Wales
Ku-ring-gai local government area, New South Wales
Liverpool City local government area, New South Wales
Lane Cove Municipality local government area, New South Wales
Mosman Municipality local government area, New South Wales
North Sydney local government area, New South Wales
Parramatta City local government area, New South Wales
Penrith City local government area, New South Wales
Randwick City local government area, New South Wales
Ryde City local government area, New South Wales
Strathfield Municipality local government area, New South Wales
Sutherland Shire local government area, New South Wales
Sydney City local government area, New South Wales
The Hills Shire local government area, New South Wales
Waverley local government area, New South Wales
Willoughby City local government area, New South Wales
Wollondilly Shire local government area, New South Wales
Wollongong local government area, New South Wales
Woollahra local government area, New South Wales
Which affected locations in Queensland have you spent the most time in?* must provide value
Brisbane local government area Logan local government area Ipswich local government area Redlands local government area Moreton Bay regional local government area Other
Which affected locations in Victoria have you spent the most time in?* must provide value
Which affected locations in South Australia have you spent the most time in?* must provide value
Which affected locations in Tasmania have you spent the most time in?* must provide value
Which affected locations in Tasmania have you spent the most time in?* must provide value
Which affected locations in the Northern Territory have you spent the most time in?* must provide value
When were you last in an affected location?If you have not yet arrived in the ACT, please indicate the last time you will have been in an affected location prior to arriving in the ACT.
* must provide value
Today D-M-Y
What date will you be arriving in the ACT?* must provide value
Today D-M-Y
Please reselect the dates provided above. The date you were last in an affected location, cannot be after the date you have arrived or will arrive into the ACT.
HIDDEN - CALCULATED LAST DAY OF MONITORING* must provide value
Today D-M-Y
Do you currently have any COVID-19 symptoms?
E.g. fever, cough, shortness of breath, sore throat, runny nose/ blocked nose, headache, lethargy, diarrhoea, loss of taste and loss of smell?
* must provide value
Yes
No
ACT Health will not be considering exemption requests, except in extreme extenuating circumstances.
If you have extenuating circumstances and would like to apply for an exemption from quarantine, please submit an application for exemption using this link . Please note that unless you receive an approved exemption, you cannot exit quarantine.Â
Â
Please DO NOT press the submit button below. As you are not required to complete this form, you do not need to provide us with any personal information at this time.
First Name* must provide value
Last Name* must provide value
Date of birth* must provide value
D-M-Y
Phone Number (Mobile preferred)
Mobile phone numbers need to be formatted in international format (+614..). If your phone number starts with 0404 remove the first 0 and add 61 at the start so it would be 61404------
* must provide value
Email Address* must provide value
ACT Health will be in contact by SMS daily throughout your quarantine period.
I do not have a mobile and would prefer to receive ongoing communication via email
Will you be staying in a home or hotel during your time in the Australian Capital Territory?* must provide value
Home: Private Residential Address
Hired accommodation: Hotel/Motel/Serviced apartment
Facility: Aged Care, Assisted Living, Correctional, Other Facility
Other (specify below)
Address while in the Australian Capital Territory:
Street Address :* must provide value
* must provide value
Acton (ACT) Ainslie Amaroo (ACT) Aranda Banks Barton Beard Belconnen Bonner Bonython Braddon Bruce (ACT) Calwell Campbell Canberra Airport Capital Hill Casey Chapman Charnwood Chifley (ACT) Chisholm (ACT) City Conder Cook Coombs Crace Curtin Deakin Denman Prospect Dickson Downer Duffy Dunlop Evatt Fadden Farrer Fisher (ACT) Florey Flynn (ACT) Forde Forrest (ACT) Franklin (ACT) Fraser Fyshwick Garran Gilmore (ACT) Giralang Gordon (ACT) Gowrie (ACT) Greenway Griffith (ACT) Gungahlin Hackett Hall Harrison Hawker (ACT) Higgins Holder (ACT) Holt Hughes (ACT) Hume Isaacs Isabella Plains Jacka Kaleen Kambah Kingston (ACT) Latham (ACT) Lawson (ACT) Lyneham Lyons (ACT) Macarthur (ACT) Macgregor (ACT) Macquarie Mawson McKellar Melba Migratory - Offshore - Shipping (ACT) Mitchell (ACT) Molonglo Monash (ACT) Moncrieff Narrabundah Ngunnawal Nicholls No usual address (ACT) Oaks Estate O'Connor (ACT) O'Malley Oxley (ACT) Page Palmerston (ACT) Parkes (ACT) Pearce Phillip Pialligo Red Hill (ACT) Reid (ACT) Richardson Rivett Russell Scullin Spence (ACT) Stirling (ACT) Symonston Taylor Tharwa Theodore (ACT) Throsby Torrens Turner Uriarra Village Wanniassa Waramanga Watson Weetangera Weston (ACT) Wright Yarralumla ACT Remainder - Belconnen ACT Remainder - Booth ACT Remainder - Coree ACT Remainder - Cotter River ACT Remainder - Gungahlin ACT Remainder - Hall ACT Remainder - Jerrabomberra ACT Remainder - Kowen ACT Remainder - Majura ACT Remainder - Molonglo Valley ACT Remainder - Paddys River ACT Remainder - Rendezvous Creek ACT Remainder - Stromlo ACT Remainder - Tuggeranong ACT Remainder - Weston Creek
Postcode* must provide value
2600 2601 2602 2603 2604 2605 2606 2607 2609 2611 2612 2614 2615 2616 2617 2618 2620 2900 2902 2903 2904 2905 2906 2911 2912 2913 2914
A separate registration form needs to be completed for each member of a household who is travelling into the ACT, even if you are quarantining together.
Has the above information been filled out on behalf of a child or dependant?* must provide value
Yes
No
Full name of person filling out form (not dependant's name):* must provide value
Declaration - Please acknowledge that you understand the following: Declaration - Please acknowledge that you understand the following:* must provide value
I understand that I am required to quarantine for 14 days (since I last visited an area of concern) upon entry into the Australian Capital Territory (ACT) unless exempted from this requirement.
Declaration - Please acknowledge that you understand the following:* must provide value
I understand that if I cannot supply a suitable premises for mandatory quarantine, I am responsible for the costs associated for the Government approved accommodation.
Declaration - Please acknowledge that you understand the following:* must provide value
I undertake to present for a COVID-19 test if I develop symptoms consistent with COVID-19 within 14 days of entering the ACT.
Declaration - Please acknowledge that you understand the following:* must provide value
I acknowledge that the information collected by ACT Health may be shared with other government agencies (including ACT Policing and Government agencies outside the ACT Government) for the purposes of identity verification and the monitoring and enforcement of compliance with State and Territory public health laws.
Declaration - Please acknowledge that you understand the following:* must provide value
I declare that the information I have provided in this application is true and correct to the best of my knowledge. I acknowledge that if this application is found to have knowingly provided false, misleading or incorrect information ACT Health may void an exemption granted on the basis of this application, and I may be charged with an offence(s) under the ACT Criminal Code 2002 which carries significant penalties.
Date of declaration* must provide value
Now D-M-Y H:M:S Please press the 'NOW' button
ACT
NSW
VIC
QLD
SA
TAS
WA
NT
Does this person need to quarantine? (eg. identified that they were only transiting through Melbourne, therefore no need to quarantine or casual contact)
Yes
No
HIDDEN: Defaulted quarantine classification Individual from a COVID-19 affected area Returned Overseas Traveller - Hotel/Home Quarantine Returning Overseas Traveller - Unaccompanied Minor Family member quarantining with returned overseas Unaccompanied minor Returning Diplomat Returning Family Member of Diplomat Diplomat Quarantining with Returned Family members Family member/s quarantining with returned Diplomat Government Officials Returning Family Member of Government official Parliamentarian Parliamentarian staffer/ family member Family member/s (or staffers) quarantining with returned Parliamentarian (international travel) AFP notified - Traveller from Victoria Traveller from Victoria Family member/Housemate quarantining with Close contact/Interstate traveller (Cannot physically distance) Other
HIDDEN: Dispatch Zone City-12 City-06 Gungahlin-07 Belconnen-19 Tuggeranong-20 City-18 City-21 Belconnen-16 Gungahlin-08 Tuggeranong-15 City-09 Belconnen-20 Tuggeranong-16 City-17 City-23 City-14 Gungahlin-03 Woden-09 Belconnen-06 Woden-14 Tuggeranong-12 City-10 Tuggeranong-18 Belconnen-18 Woden-03 Gungahlin-12 Woden-16 Woden-17 Woden-01 City-04 City-02 Woden-06 Belconnen-01 Belconnen-25 Tuggeranong-09 Woden-23 Woden-13 Belconnen-11 Belconnen-08 Gungahlin-09 Woden-28 Gungahlin-17 Belconnen-07 City-19 Woden-26 Tuggeranong-11 Belconnen-23 Tuggeranong-19 Tuggeranong-08 Tuggeranong-05 Woden-30 Gungahlin-14 City-05 Gungahlin-01 Gungahlin-15 Belconnen-13 Belconnen-04 Woden-07 Belconnen-03 Woden-18 Woden-33 Woden-24 Tuggeranong-14 Gungahlin-06 Belconnen-22 Tuggeranong-02 Woden-29 Belconnen-05 Belconnen-21 City-03 Woden-15 Tuggeranong-10 Belconnen-02 Belconnen-17 Woden-22 Belconnen-24 Belconnen-10 Migratory - Offshore - Shipping (ACT) Gungahlin-18 Woden-02 Tuggeranong-07 Gungahlin-05 Woden-31 Gungahlin-10 Gungahlin-11 No usual address (ACT) City-22 City-07 Woden-25 Tuggeranong-04 Belconnen-14 Gungahlin-13 City-15 Woden-20 Woden-19 City-20 Woden-27 City-11 Tuggeranong-13 Woden-08 City-17 Belconnen-12 Belconnen-09 Woden-10 Woden-32 Gungahlin-04 Tuggeranong-21 Tuggeranong-17 Gungahlin-16 Woden-21 City-08 Woden-05 Tuggeranong-03 Woden-12 City-01 Belconnen-15 Woden-11 Woden-04 City-13 ACT Remainder - Belconnen ACT Remainder - Booth Woden-34 ACT Remainder - Cotter River ACT Remainder - Gungahlin ACT Remainder - Hall ACT Remainder - Jerrabomberra ACT Remainder - Kowen ACT Remainder - Majura ACT Remainder - Molonglo Valley ACT Remainder - Paddys River ACT Remainder - Rendezvous Creek Tuggeranong-01 Tuggeranong-06 ACT Remainder - Weston Creek
Working...