COVID19 Wavier Form V2 | URBACON COVID19 Survey Site

URBACON COVID-19 Site Screening Survey

COVID19 Waiver Form

Select the Job Site you are attending:

Your Email address:

Your full name:

What company are you with:

Have you had ANY of these symptoms in the last 14 days? (high temperature, fever or chills, difficulty breathing or shortness of breath, sore throat, trouble swallowing, cough, runny nose/stuffy nose or nasal congestion, decrease or loss of smell or taste, nausea, vomiting, diarrhea, abdominal pain, not feeling well, extreme tiredness, sore muscles)

Yes

Is there anyone in your household exhibiting the above symptoms?

Yes

To the best of your knowledge, have you been in contact with someone with a confirmed or probable case of COVID-19?

Yes

Have you travelled outside of Canada in the last 14 days?

Yes

Have you been in contact with anyone in your household who has travelled outside of Canada in the last 14 days?

Yes

Have you been tested for COVID-19 and are currently awaiting results?

Yes

Have you received a positive COVID-19 test result?

Yes

Having answered Yes to the previous question, have you been cleared to return to work from your local health unit?

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

Question7

YesNoTotal