Covid-19 Acknowledgement Form

Please fill out this form to the best of your knowledge.

In the interest of the Health and Safety of all works on the project, you are required to complete this Declaration to the best of your ability and knowledge.

Prior to the start of each shift, please answer all questions below. When you are done ensure you submit the form. This declaration will be kept on file in the office. Any development of flu-like symptoms must be reported to Management immediately. 

Your First Name
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Field is required!
Your Last Name
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Field is required!
Have you traveled outside of Canada in the past 14 days?
Field is required!
Field is required!
Select a date
Field is required!
Field is required!
Do you have any of these symptoms?
If no symptoms present, please select none of the above
If no symptoms present, please select none of the above
Other Symptoms
Describe your other symptoms
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Field is required!
Have you knowingly had any contact with anyone with confirmed COVID-19?
Field is required!
Field is required!
Date of Contact
Select a date
Field is required!
Field is required!
Have you been informed that you have COVID-19 or were you informed by any health organization to go for screening?
Field is required!
Field is required!
Has your test been completed?
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Field is required!
Date of Test
Select a date
Field is required!
Field is required!
Field is required!
Field is required!
Declaration
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Field is required!
Submit