This form should be completed by a traveller or person on their behalf who is requesting for a change in mandatory quarantine arrangements due to exceptional circumstances.

If a request is required for more than one person (e.g. a family), one application must be completed for each person, however you will be asked in each application who you will be travelling with.

Please ensure to provide as much information as possible to support the review of applications.

If this is an emergency, call 000.

Privacy Statement

To enable your request to be considered, the Department of Health and Human Services (‘the department’) requires information from various sources, including health and pathology services, medical practitioners and other relevant professionals who can assist in verifying your circumstances relating to your request. We collect this information to lessen or prevent a serious threat to public health and safety from the COVID-19 virus pandemic and consider your personal circumstances in relation to your request.

The information you provide, and that we collect about you, will be used to monitor your compliance with directions by the Chief Health Officer under the Public Health and Wellbeing Act 2008, and may be used and disclosed for investigation, enforcement, public health research, and as authorised or permitted by law. The department may share your information with Victoria Police, law enforcement bodies, healthcare services and researchers for these purposes. Your information may continue to be used and disclosed for these purposes after you leave detention or are subject to a direction by the Chief Health Officer.

You can apply for access to information the department holds about you. The department’s Freedoms of Information Unit may be contacted on: Email:

For information on the department’s Privacy policy ( or on how the department manages privacy, please contact the Privacy Unit: