Covid-19 Orientation & Declaration Statement

Covid-19 Orientation & Declaration Statement
Prime Company Name
We seek to ensure the health and safety of all our workers and sub-trades on our job sites. As part of our safety program you are required to fill out and submit this orientation/declaration prior to starting work.
Job Site:
Subcontractor
I understand that if I am sick with flu/cold symptoms I am required to stay at home (self-isolate) for 14 days.

Agree
I have been informed regarding sanitation requirements (Hand-washing prior to site entry).

Agree
I have been informed regarding respiratory hygiene (Cough into your sleeve or elbow)

Agree
I have been informed regarding social distancing (Keep 2m (6') away from others)

Agree
I have been informed regarding regular sanitizing of shared tools, equipment, etc.

Agree
Have you traveled outside of Canada in the past 14 days?

YesNo
If Yes, date returned:

MonthDayYear
Date
Do you have, or have had any cold/flu-like symptoms in the previous 14 days? Symptoms include: Fever, dry cough, sore throat, shortness of breath, fatigue.

YesNo
Have you been in close contact with anyone who has tested positive for Covid-19

YesNo
If Yes, date of contact:

MonthDayYear
Date
Have you tested positive for Covid-19 or have you been told to go for screening by a health authority?

YesNo
If Yes, Test date:

MonthDayYear
Date
Test results:

NegativePositive
I understand that by submitting this document I am declaring that all statements, to the best of my knowledge, are factual and true, and that should any of the facts concerning these declarations change in the future, I will immediately notify the site supervisor.
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty: