Self-Isolation Plan
This form is to be completed by each traveller.
TRAVELLER’S DETAILS
Application ID:
Employer name:
Your full name
(as shown on your passport):
Home address
(usual residence):
Mobile phone number
(must work in New Zealand):
Email address:
EMERGENCY CONTACT DETAILS
We will contact this person if there is an emergency situation during your 14 day self-isolation
Name:
Address:
Phone number:
Email address:
Relationship to traveller:
NHI NUMBER AND GP’S CONTACT DETAILS
NHI number (if known):
Medical Centre:
Name of GP:
Address:
Phone number:
Email address:
SELF-ISOLATION INFORMATION
Self-isolation address
(residence for the 14 day stay):
Property information:
A.
I own the property in which I will self-isolate
B.
I rent and live in the property in which I will self-isolate
C.
I (or my employer) will temporarily rent/lease/borrow the property in which I will self-isolate
If B or C is selected, answer the following:
The person I am renting/leasing/borrowing the property from:
(a) is aware that the property will be used for self-isolation; and
(b) has agreed to that use; and
(c) has agreed to signage being placed on the property to show that someone is self-isolating there; and
(d) understands that they cannot enter or visit the property during the period of self-isolation.
MANAGED ISOLATION ALLOCATION SYSTEM – VOUCHER TO BOARD YOUR FLIGHT TO
NEW ZEALAND
If you are accepted into the pilot, you will be issued a voucher in the Managed Isolation Allocation System based on your
flight number and arrival date. This voucher is required to board your fight to New Zealand even though you will not be
going into a managed isolation facility. You will not be permitted to board your flight without showing your voucher.
I have registered an account in the Managed Isolation Allocation System.
I understand that I will need to present my voucher when checking in for my flight to New Zealand.
PRIVACY STATEMENT AND DECLARATION SECTION
The address I will self-isolate at meets the following requirements:
For Christchurch: The address is within 50km (by road) from Christchurch International Airport
OR
For Auckland: The address is within 50km (by road) from the Auckland International Airport and within the
boundary of Auckland Council.
I will self-isolate alone or with the following approved pilot participants who are travelling with me:
I understand and agree that no one else can visit, live or stay with me while I am in self-isolation.
I will remain in my place of self-isolation for at least 14 days until I am authorised to leave by MIQ. I will not leave
the property at any time unless in an emergency or where I am escorted by a person authorised by MIQ.
The rented/leased property is a private dwelling (for example not a hotel/motel)
The property is not a room or rooms or part of another dwelling (even if it is separated eg a separate storey).
The property is not in an apartment block.
The property does not share internal access with other properties (e.g., no shared pathways, stairwell, lift, garage
or other indoor or outdoor spaces) where I could come into contact with anyone other than approved pilot
participants who are isolating with me.
I will display signage provided to me on every entrance/door to the property at all times
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The property does not share ventilation systems with any other property.
The property has opening windows in the living, bedrooms and bathroom areas.
I will have reasonable access to an area for exercise within the property grounds.
I will have access to an outside space which is not shared by anyone other than approved pilot participants
isolating with me.
I will have access to potable running water, heating, lighting, a functional sewage disposal system and be able to
safely dispose of household waste.
I will have reliable means of communication available (a New Zealand mobile phone at a minimum, landline and/or
internet connection) and the property has at least a 3G cellular coverage.
I will have access to food and medication without leaving the address or having any visitors (note that contactless
delivery of groceries/food is permitted).
I will be responsible for cleaning the accommodation during my stay.
I am aware that a deep clean specified by MIQ will be required if I test positive for COVID-19 while self-isolating
and that the property can not be occupied until the clean has occurred.
I do not have any medical needs or other requirements which mean that I will need to leave the property or have
any visitors in the 14 days I am in self-isolation.
I will not allow any visitors to enter the premises, aside from medical staff for testing purposes and emergency
or other essential services if required (e.g. fire, ambulance, police, tradespeople for urgent repairs if they are
approved by MIQ).
PURPOSES OF INFORMATION COLLECTION
The information you provide in this form is being collected by, and will be stored by, the Ministry of Business,
Innovation and Employment (MBIE). The subsequent management of your self-isolation once you return to
New Zealand will involve a number of government agencies in addition to MBIE.
The information collected from you will be used to:
ȓ administer the pilot, including to:
– make decisions regarding participation in the pilot;
– manage the flow of people arriving in New Zealand, and transport to and from places of self-isolation and, if
required, to managed isolation or quarantine facilities;
– arrange testing required as part of the pilot including enabling the Ministry of Health to produce or retrieve a
participant’s National Health Index Number; and
– manage your progress throughout and compliance with the requirements of the self-isolation pilot
ȓ contact individuals regarding the pilot, including to request further information or evidence if needed, and for
research and evaluation purposes including after participants have completed self-isolation
ȓ validate information provided by individuals, including validation of travel and visa information with Immigration
New Zealand and vaccination status with the Ministry of Health
ȓ determine any liability to pay fees or charges for managed isolation and participation in the pilot, and invoicing for
those fees or charges,
ȓ facilitate management of requests for and access to health or wellbeing assistance or advice, including informing
nominated general practitioners or medical providers of the period that a participant will be in self-isolation.
ȓ monitor compliance with, and respond to any actual or suspected breaches of the:
– COVID-19 Public Health Response Act 2020 and orders made under that Act, including the COVID-19 Public
Health Response (Isolation and Quarantine) Order 2020; and
– requirements of the self-isolation pilot
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ȓ evaluate, monitor and report on the pilot, including its progress and outcome.
ȓ administer and improve the Managed Isolation and Quarantine (“MIQ”) function.
If all of the information requested on this application, and any further information requested, is not provided, you
may not be able to participate in the self-isolation pilot.
USE OF PERSONAL INFORMATION
We will generally only use personal information provided to us in relation to the pilot, including through this website,
for the purposes for which it is collected set out above.
We may also use personal information provided to us where required or permitted by law (e.g. with your consent,
for a directly related purpose, or where necessary to prevent or lessen a serious threat to the life or health of an
individual or to public health).
DISCLOSURE
When you provide personal information, unless otherwise indicated, it will be collected and held by or on behalf of
MBIE. Your nominated general practitioner details and NHI number (if known) are collected by MBIE on behalf of the
Ministry of Health.
Information you provide in this form, and subsequently when you are participating in the self-isolation pilot, will
be shared with the Ministry of Health and may be managed within their secure National Border Solution and Border
Clinical Management Systems. The relevant Privacy Statement
is here.
Information provided on this form or as part of the pilot may be disclosed to or accessed by third parties to the
extent required for them to perform their role in the self-isolation pilot, including: the relevant district health board
or public health unit, health care providers, call centre staff managing checking processes and health care, contact
tracers, New Zealand Customs Service, the New Zealand Police, third parties providing technology services in relation
to compliance monitoring, emergency services, the airline on which and airport at which a participant arrives in
New Zealand, transport operators, and security companies engaged by MBIE.
Information collected on this form, and during the pilot, including information regarding a participant’s ineligibility
for the pilot (whether collected before or during the pilot) may be provided to a participant’s employer.
Information may be disclosed to the New Zealand Police in order to detect, investigate and/or respond to any
actual or suspected breaches of the law, including breaches of the COVID-19 Public Health Response (Isolation and
Quarantine) Order 2020.
It may also be stored or accessed on behalf of MBIE by authorised third parties (such as third-party contractors) to
the extent that is necessary, for example for them to administrate or work on the site.
We will store and k
eep your personal information secure in accordance with the Privacy Act 2020.
RECORDS AND RETENTION OF PERSONAL INFORMATION
We will only retain personal information collected for the purposes of the pilot as long as it is required for the
purposes for which the information may lawfully be used.
Public records
Where any information provided (which may include personal information) to, or through, this site constitutes public
records, it will be retained to the extent required by the Public Records Act 2005.
W
e may also be required to disclose information under the Official Information Act 1982 or to a Parliamentary Select
Committee or Parliament in response to a Parliamentary Question.
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Security
Our websites have security measures in place to prevent the loss, misuse and alteration of information under
our control. To maintain the cyber security of our systems and information, our systems are subject to ongoing
monitoring (including activity logging), analysis and auditing.
We may use information about your use of our websites and other IT systems to prevent unauthorised access or attacks
on these systems or to resolve such events. We may use this information even if you are not involved in such activity.
We may use services from one or more third-party suppliers to monitor or maintain the cyber security of our systems
and information. These third-party suppliers will have access to monitoring and logging information as well as
information processed on our websites and other IT systems.
Security measures have been implemented to secure and protect your personal information.
RIGHTS OF ACCESS AND CORRECTION
Your rights
You have the right to:
ȓ find out from us whether we hold personal information about you
ȓ request access to that information; and, if applicable
ȓ request correction of that information.
If we have a good reason for refusing a request for correction, you are entitled to request that a statement be
attached to the information correction that was sought but not made.
If you want to check personal information that we hold, please write to:
Privacy Officer
Ministry of Business, Innovation and Employment
PO Box 5488 Wellington 6011.
Alternately you can contact the MIQ Service Centre via the
MIQ website and request your personal information.
For more information on the privacy laws in New Zealand and contact details for the Office of the Privacy
Commissioner
, visit the Privacy Commissioner’s website.
Changes to this privacy notice
We may update this privacy statement from time to time. You are encouraged to review new versions as they are
published.
Current version published 15 October 2021
To obtain previous versions of the privacy statement please contact us via the
MIQ website.
DECLARATIONS
Please tick the boxes below:
I have read and understood the self-isolation pilot privacy statement.
I am able to and will meet the requirements of the pilot and provide verification of the requirements,
if requested. Requirements include that I:
ȓ am a New Zealand citizen or holder of a residence class visa with the right to re-enter New Zealand,
ȓ will arrive in New Zealand via direct international flight into Auckland or Christchurch during the period
30 October to 8 December 2021
ȓ am or will have been fully vaccinated in New Zealand with two Pfizer vaccinations prior to departure
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ȓ have arranged self-isolation accommodation in a private dwelling with cellular coverage and no shared
ventilation, that is within 50km (by road) of the Christchurch International Airport or 50km (by road) of the
Auckland International Airport and within the boundary of Auckland Council
ȓ will undergo 14 days of isolation in Auckland or Christchurch alone or with members of the travelling party
named in the Expression of Interest submitted by me or on my behalf
ȓ will have a working smartphone for the duration of self-isolation
ȓ will comply with all monitoring requirements which include having a working smartphone for the duration of
self-isolation, and responding to communications (including calls and video calls) for monitoring purposes,
ȓ will ensure a notice regarding self-isolation is and remains displayed at every entry point to my place of self-
isolation, including at each entry point to the accommodation at my place of self-isolation accommodation,
ȓ will maintain physical distancing (to the greatest extent practicable) from everyone except any fellow traveller
participant;
ȓ wear personal protective equipment (to the greatest extent practicable) at all times when outside my place
of self-isolation; and at any other times I they are directed to do so by a medical officer of health or a health
protection officer;
ȓ will only exercise in an outside area at my place of self-isolation, if the outside area is within the boundary of
the property or unit of my place of self-isolation; and the area is only used by authorised persons during the
period of self-isolation
ȓ will remain at my place of self-isolation except as permitted under the COVID-19 Public Health Response
(Isolation and Quarantine) Order 2020
ȓ will ensure that only authorised persons enter my place of self-isolation, including a person who needs to
enter to: deliver goods in a way that maintains physical distancing from others; provide any necessary medical
services, including any test for COVID-19; preserve or protect their own or another person’s life, health, or
safety in an emergency; or who is authorised by MBIE’s chief executive
ȓ will comply with all legal and health requirements, including medical examination and testing for COVID-19 and
health and wellbeing check.
I understand that I may be requested to provide further information or evidence to support any information
provided on this form, and agree that I will update this information if it changes during my period of self-
isolation.
I understand that providing false or misleading information may result in ineligibility for the pilot, and may
constitute an offence.
I understand and agree that if I do not comply with the requirements of the pilot I may be required to complete
the remainder of my period of isolation and quarantine in a Managed Isolation or Quarantine Facility.
I understand and agree that the information provided on this form, and information regarding any non-
compliance with the requirements of the self-isolation pilot may be provided to my employer.
I understand that intentionally failing to comply with any order made under the COVID-19 Public Health Response
Act 2020 (Act), including the COVID-19 Public Health Response (Isolation and Quarantine Order) 2020, constitutes
an offence under the Act.
I declare that the information provided on this form is true, complete, up-to-date and accurate, to the best of my
knowledge, and that I have read, understood and agree to this declaration.
Name:
Signature:
Date signed:
DD/MM/YYYY
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SIP 7255
