Administrative code for internal use only: Please leave blank.
HIDDEN: Dummy variable to hide interstate traveller dec number on new non-act applications Dummy variable to hide interstate traveller dec number on new non-act applications
Please indicate if you are an ACT or non-ACT resident
* must provide value
I am a resident of the ACT I am a non-ACT resident
According to the information in the blue and green boxes above, do you need to apply for an exemption from quarantine?* must provide value
Yes
No
DO NOT SUBMIT THIS FORM IF YOU ARE EXEMPT FROM QUARANTINE.
Only submit this form if you have an extenuating circumstance and want to apply for an exemption from quarantine.
What is your Interstate Traveller & Returning Resident Self-Declaration unique reference number? Please complete if you have a reference number from declaring your entry to the Australian Capital Territory (ACT).
Select the type of travel
Domestic
International
(hidden) Select the type of travel
Domestic
International
Select the traveller classification which best describes you:
Interstate travellers and residents
Parliamentarians and staff (including partner/ dependents)
(hidden) Select the traveller classification which best describes you:
Interstate travellers and residents
Parliamentarians and staff (including partner/ dependents)
What interstate location was this person from NSW
Victoria
Which State or Territory are you travelling from?
* must provide value
NSW
QLD
HIDDEN: NSW Traveller Non-ACT resident exemption to enter ACT data point NON-ACT resident from NSW requiring exemption to cross border
HIDDEN: QLD Traveller Non-ACT resident exemption to enter ACT data point NON-ACT resident from QLD requiring exemption to cross border
Select the traveller classification which best describes you:
Returning Diplomats (including partner/ dependents)
Returning Government Officials (including partner/ dependents)
Returning overseas traveller/ resident
The national requirements for persons arriving to Australia from overseas are that they must enter into hotel quarantine at the port of entry. If you are a returning traveller with exceptional circumstances seeking to quarantine in the ACT instead of your port of entry, or to quarantine at your home instead of an ACT hotel, you must fill out the form below.
Port of Entry into Australia:
Please note that if the port of entry is in another State or Territory, permission must also be gained from that jurisdiction for onward travel to the ACT.
With which embassy/ sponsor agency are you associated?
Evidence of this association must be supplied, and will be verified against ACT Health records.
If you are applying for this exemption on behalf of someone else, please indicate your contact details:
Select the subclassification which best applies to you:
Diplomat/Parliamentarian/Government Official
Spouse/Partner
Child/dependent
Staffer of official/parliamentarian/diplomat
What is the name of the diplomat/parliamentarian/government official this person is attached to?
If the person is a family member of a staffer of an official/parliamentarian please include the name of the staffer and in brackets the official they work for.
E.g. If Mary was the chief of Staff for Joe Bloggs (parliamentarian) and you were completing Mary's husband Pete's record you would write: Mary (Joe Bloggs MP).
Date Submitted:
Today D-M-Y
Today D-M-Y
Please tick the box to declare the following:* must provide value
I am allowed to travel under current public health restrictions
Have you been in the Northern Beaches Local Government Area since December 11th?* must provide value
Yes
No
Have you been at a venue, location or public transport route at the same time as a confirmed case, as identified by NSW Health?
* must provide value
Yes
No
What venue, location or public transport route have you been at and at what times?
Please copy/paste the venue, location or public transport route from the NSW website
* must provide value
What affected LGA have you spent the most time in?
None of the above None of the above
What affected LGA have you spent the most time in? Northern Beaches local government area, New South Wales 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
None of the above
What affected LGA 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
You are not required to apply for an exemption to enter the ACT. Only people who have been in the affected areas listed above need to apply for an exemption.
Have you been in, or will you be, in an identified area of concern or restriction within 14 days prior to your travel to the ACT?
If your situation changes and you enter an identified area of concern you are required to notify ACT Health as soon as possible.
* must provide value
Yes
No
Was your time in the area of concern restricted only to transit purposes, either:
Transit directly to Melbourne airport for the purpose of travelling to another state/territory by air; or Transit* directly through the area of concern or restriction. *Transit may include stops kept to a safe minimum at isolated rest areas, with minimal interactions and appropriate precautions taken. Advice on staying safe can be found here .
* must provide value
Yes
No
Have you had, or will you have, any household contact with a person who travels into an identified area of concern or restriction in Victoria, within 14 days prior to your travel to the ACT?
If your situation changes and you have household contact with someone who has entered an identified area of concern you are required to notify ACT Health as soon as possible.
* must provide value
Yes
No
Declaration - Please acknowledge that you understand the following:
I declare that: • I have not been, and will not be, in an identified area of concern or restriction in Victoria (other than for transit purposes*),
• I have not had, and will not have, any household contact with a person who travels into an identified area of concern or an area of restriction in Victoria, within 14 days prior to my travel to the ACT.
• I understand that making a false or misleading declaration, or providing false or misleading information as part of my exemption application, is an offence which is subject to significant penalties of up to $16,000, imprisonment for 1 year (or both).
• If my situation changes and I enter an identified area of concern I will notify ACT Health as soon as possible.
* must provide value
I understand and acknowledge the declaration
*Transit purposes may include stops kept to a safe minimum at isolated rest areas, with minimal interactions and appropriate precautions taken.
Do you also need to apply for a person under the age of 18? Yes
No
You must still fill out a separate form for each individual person regardless of age. If you don't have ID for someone under the age of 18 upload the parent's ID. Please list the names of any person under the age of 18 that you would like your exemption to be considered alongside.
What is the reason you are applying for an exemption?* must provide value
Providing essential services in the Australian Capital Territory (ACT) A person seeking a permit on compassionate grounds e.g. visiting a family member receiving palliative care Needing to receive or attend a service during quarantine, including medical care Entering for child access or critical care arrangements Required to attend court or legal proceeding Moving to the Australian Capital Territory Student Other urgent reason - provide details below
What essential service would you provide in the Australian Capital Territory (ACT)? * must provide value
Health Care Worker (See additional Notes in section 3) Government Worker, law enforcement, military Member of parliament or staff Education Agriculture Construction, engineering or manufacturing Maintenance or repair of critical infrastructure Flight crew Removalist Other
What 'other' essential service would you provide?
Please note that you MUST provide the relevant supporting documentation as per Section Four otherwise your application can not be assessed.
Note: If you are indefinitely relocating to the ACT for work then please select the category ‘moving to the ACT'.
If you are moving to the ACT, you must provide the following documentation:
Proof of permanent employment in the ACT (letter from employer); or proof of long term accommodation arrangements greater than six months; AND Two forms of ID (photo ID and proof of current address). Applicants applying for essential worker status in construction, engineering and manufacturing MUST upload supporting documentation that provides details of the following:
Name of project, description of project and location
Details of Head Contractor and contact details
Nature of the services they are performing
Confirmation as to whether it is an ACT Government or private project
A reference from the head contractor setting out the critical need for the services to be provided
Supporting documents can be attached in section three of this form.
Note: If either of these situations apply to you, you do not need to complete this form:
Entering via air to the Canberra airport and transiting to another jurisdiction by air, and do not leave the Canberra airport OR Entering the ACT by road with no stops, travelling directly through the ACT. You do not need to complete this form, but you must ensure that you have a permit for the jurisdiction to which you are travelling.
Please provide details of your request for an exemption:* must provide value
Mr Ms Mrs Dr
First Name:* must provide value
Last Name:* must provide value
* must provide value
D-M-Y
Personal email address* must provide value
Phone number while in the Australian Capital Territory (ACT)?* must provide value
Required Quarantine Start Date:
Today D-M-Y
Address while in the Australian Capital Territory (ACT)* must provide value
Suburb* must provide value
Postcode* must provide value
Will your accommodation in the Australian Capital Territory (ACT) be paid accommodation (E.g. Hotel/Motel/Other paid accommodation)?* must provide value
Yes
No
If you plan to stay in paid accommodation during your time in the Australian Capital Territory (ACT), please do not book until after your exemption has been approved, as if you are required to quarantine, you will need to stay in an approved hotel. The Office of the Chief Health Officer will contact you with a list of approved hotels.
For the Australian Capital Territory (ACT) paid accommodation and address fields, please enter "TBC" unless you have already booked your accommodation.
Please note that if you are approved to enter the ACT and required to quarantine, you will need to ensure the hotel is aware you will be in quarantine and has confirmed your arrival time - particularly if arriving early. You should also be aware that you will need to book 15 nights of accommodation in order to meet the ACT's mandatory quarantine requirements.
Please note if you are quarantining at a residential address, you must be appropriately separated from any other residents at the address. Appropriate separation means that you have access to a separate bedroom and bathroom. You must also ensure that all other people residing at the address are made aware of your requirement to quarantine.
Please note if you are quarantining at a residential address, all other residents of the household will need to be in quarantine if you are granted entry to the ACT. Please list the names of any other person(s) who will be residing at this household during your quarantine.
Please provide the name of the paid accommodation* must provide value
List the name(s) of any other person(s) residing in this household during your quarantine:
Please declare you understand the following by ticking the box:* must provide value
You grant ACT Health permission to contact the paid accommodation you intend to stay at to assess the appropriateness of the accommodation for quarantine purposes.
Are you able to suitably quarantine at the Australian Capital Territory (ACT) address you have provided?
* must provide value
Yes
No
Suitable quarantine means that the accommodation needs to allow for appropriate separation from other household members who are not in quarantine. Household members in quarantine must have a separate bedroom, and separate bathroom if possible, and must avoid spending time in communal spaces at the same time as other people in the home who are not in quarantine.
* must provide value
I declare that I have read the above definition of suitable quarantine and confirm that I understand the requirements and will have access to a separate bedroom and bathroom at my quarantine address
Will any other persons be at this address while you are undertaking quarantine?* must provide value
Yes
No
All other people residing at this address must be made aware of your requirement to quarantine
Is the above Australian Capital Territory (ACT) address the same as your usual residential address?* must provide value
Yes
No
Details of permanent residential address if different to address while in Australian Capital Territory (ACT)?* must provide value
Suburb* must provide value
Postcode* must provide value
State:* must provide value
ACT
NSW
VIC
QLD
SA
TAS
WA
NT
Date of entry to the Australian Capital Territory (ACT)
* must provide value
Today D-M-Y
IMPORTANT NOTE: If your exemption is granted, this is the date you will be required to enter the ACT. The exemption will not be valid for any other date.
Date you were last in a COVID-19 affected area
* must provide value
Today D-M-Y
What is the earliest date you want an exemption from quarantine?
E.g. What is the date of your medical appointment, or first date you would need to attend work. * must provide value
Today D-M-Y
Date of proposed Departure from the Australian Capital Territory (ACT)?
* must provide value
Today D-M-Y
Date of proposed Departure from the Australian Capital Territory (ACT)
* must provide value
Today D-M-Y
Please provide details of the locations in Victoria which you will have visited in the 14 days prior to your entry to the ACT.* must provide value
Please detail where overseas you have been in the past 30 days?
What is your planned mode of entry into the Australian Capital Territory?
* must provide value
Private Vehicle Plane Bus Train Other (please specify)
Please provide details of your mode of transport. If travelling via air, please provide your flight number, route and date. * must provide value
Approximate time you will arrive in the ACT:
Now H:M
If necessary, please provide any additional details relevant to this request
OLD FIELD HIDDEN: Do you need Government accommodation organised at your own expense?
* must provide value
Yes
No
For all requests please provide the following supporting documentation:
Identification - must provide Drivers Licence or other form of photo ID. Moving to the ACT:
You will need to provide evidence that:
You have secured employment for at least 6 months in the ACT that requires you to relocate (this should be in a letter from your employer) OR You have a lease in the ACT of at least 6 months, and your current living arrangements are coming to an end. Essential workers:
Must provide a supporting letter from the head of the organisation AT the site where you will be working in the ACT which details the tasks you are required to undertake, the critical need for the services to be provided at this time, and why these services can only be provided by you specifically and cannot be sourced from within the ACT or any jurisdiction outside of the COVID-19 affected area.
If you are a Health Care Worker working in an ACT Hospital (Public or Private sector), you must complete a staff exemption form signed by the relevant executive of the area and attach it to this application.
Exemptions will only be considered when it can be established that:
• The staff member’s role cannot be fulfilled by another individual, either local or interstate; or
• The staff member is deemed an essential worker (defined as: there would be a greater risk posed to patients and staff if the staff member was excluded from work).
Compassionate grounds:
If you are attending a funeral, you will need to supply a death certificate or letter from the funeral service provider granting permission for your attendance.
If you are intending to enter to visit a sick or palliative family member, or require care or support from a family member in the ACT, you will need to supply supporting documentation from your or their treating medical professional outlining their or your requirement for travel.
Needing to receive or attend a service:
You will need to provide supporting documentation from the service that verifies that this service is only available in the ACT, the service is comfortable with you attending, and an explanation as to why the entry is time critical. If this is a health service then please provide a letter from the health facility and your treating medical professional.
Please provide details of your request for an exemption, noting the definitions of exceptional circumstances and required documentation below.
Entering for child access:
You will need to provide proof of legal guardianship, and court documentation where possible. Note that exemptions from quarantine are not possible and child access will need to take quarantine requirements into consideration.
All applicants must include: Passport and flight itinerary .
Grounds for exemption Additional documentation required Medical – requires urgent medical treatment in the ACT Letter from traveller’s treating medical professional Medical – hotel quarantine not appropriate for medical or mental health reasons Letter from traveller’s treating medical/mental health professional Compassionate – visiting palliative or very ill immediate family member Letter from family member’s treating medical professional which includes details of the patient’s condition. If the patient is currently in hospital, please include their date of birth and ward details. Compassionate – attending funeral of immediate family member Death certificate or letter from funeral director Compassionate – needing to provide urgent care or support to immediate family member Letter from family member’s treating medical professional Essential work – Government employee needing to work from home during quarantine Letter from employer detailing need for work at home during quarantine period Unaccompanied minor Photo identification of parent/guardian Other exceptional circumstances Any relevant documentation that validates these grounds
Required to attend court/legal proceeding:
You will need to provide evidence from the court that you are required to attend on (x date).
Residents of another state or territory seeking to return home:
You will need to show proof of address in your home state or territory. If returning to a jurisdiction other than NSW, you will also need to provide evidence of approval for your entry to that Jurisdiction. You will need to travel in a private vehicle to return home.
Please provide any further information you would like us to know about these grounds, including whether you are seeking a further exemption to your quarantine (i.e. exit from quarantine premises to attend a funeral service, visit palliated relative or obtain medical care):
If you are seeking an exemption to leave your premises during quarantine, please detail why and include your proposed mode of transport and any interactions with others:
Upload Identification - must provide Drivers Licence or other Photo ID
* must provide value
Upload Identification - must show name & home address
* must provide value
Upload evidence -Must provide letter from the head of the organisation AT the site where you will be working in the ACT which sets out the critical need for the services to be provided and that these services can only be provided by you.
* must provide value
Upload Evidence of quarantine premises (if not home address)
Upload Proof of Employment as an essential worker (where relevant)
* must provide value
Upload supporting documentation (if required)
Supporting Documentation 11 Use if exemptions team is submitting the form
Supporting Documentation 12 Use if exemptions team is submitting the form
Supporting Documentation 13
Use if exemptions team is submitting the form
Supporting Documentation 14
Use if exemptions team is submitting the form
If you need to upload more files click yes to display additional fields: Yes
No
Supporting Document 6
Supporting Document 7
Supporting Document 8
Supporting Document 9
Supporting Document 10
Declaration - Please acknowledge that you understand the following:* must provide value
I understand that I am required to quarantine for 14 days upon entry into the Australian Capital Territory (ACT) unless exempted from this requirement.
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.
I undertake to present for a COVID-19 test if I develop symptoms consistent with COVID-19 within 14 days of entering the ACT.
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.
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.
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.
Please check all your information and ensure you have uploaded the supporting documentation. Once you click the “SUBMIT” button you will not be able to go back and change your details.
If you do feel you have an issue, please feel free to contact the COVID exemptions team at COVID.Exemptions@act.gov.au
IMPORTANT: YOU MUST CLICK THE "SUBMIT" BUTTON BELOW TO LODGE YOUR APPLICATION.