Covid 19 Declaration 11172020

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In the interest of the Health and Safety of all workers at Marcon, you are required to complete this Declaration to the best of your ability and knowledge.

Please answer all the questions below. When you are done, ensure you sign at the bottom and give back to the presenter. This document is to be kept on file at Marcon. Any development of flu like symptoms must be reported to your supervisor immediately.

1. Have you travelled outside of Canada in the past 14 days?

Yes No

2. Do you have or have had any flu like symptoms presently or in the last 14 days? Symptoms include cough, sneezing, fever (over 38 Celsius/100.4 Fahrenheit), sore throat, or difficulty breathing?

Yes No

3. Have you knowingly had any contact with anyone with confirmed COVID-19?

Yes No

4. Have you been informed that you have COVID-19 or informed by any health organization to go for screening?

Yes No

5. Temperature at the time of completing the form

By signing this document, you declare all statements are true and factual to the best of your knowledge.

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Notes - i.e. record last test date and results (if available)