URBACON COVID19 Survey Site

COVID19 Waiver Form - Dec 2021

Select the Job Site you are attending:

Your Email address:

Your full name:

What company are you with:

Do any of the following apply to you? I am fully vaccinated against COVID-19 (it has been 14 days or more since your final dose of either a two-dose or a one-dose vaccine series) ** OR ** I have tested positive for COVID-19 in the last 90 days and since been cleared by the local public health unit

Yes

Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions. (fever and/or chills, cough or barking cough (croup), sortness of breath, decrease or loss of smell or taste, fatigue, lethargy, malaise, muscle aches, joint pain)

Yes

In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?

Yes

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

Yes

In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? (If you have since tested negative on a lab-based PCR test, select "No")

Yes

In the last 10 days, have you been identified as a "close contact" of someone who currently has COVID-19? (If public health has advised you that you do not need to self-isolate , select "No")

Yes

In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? (If you have since tested negative on a lab-based PCR test, select "No")

Yes

Is anyone you live with currently experiencing any new COVID-19 symptoms (listed above) and/or waiting for test results after experiencing symptoms?

Yes

You have passed and can enter the workplace.

Further screening measures may be implemented on entry to workplaces, these may include but are not limited to, entrants submitting to an infrared temperature check.

Anyone who is shown to have provided a false response to any of the above may be barred from returning to a workplace indefinitely.

You have not passed and are not permitted to enter the workplace (including any outdoor, or partially outdoor, workplaces).

You should go home to self-isolate immediately and contact your health care provider or Telehealth Ontario (1 866-797-0000) to find out if you need a COVID-19 test. Please also contact your manager immediately to inform them of your absence from a workplace.

I certify that the answers above are true as of the completion of this form:

Confirmed

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