I declare that:
- I have not been in contact with anyone with a known or probable case of COVID-19.
- I have not been in contact with anyone experiencing symptoms related to COVID-19.
- I have not been in contact with anyone who has travelled outside of the province in the past 14 days.
- I currently have no symptoms of COVID-19: for example, fever, cough, difficulty breathing, or pneumonia.
- I have not travelled outside of the province in the past 14 days.
If any item of the above do not hold true, you will not be permitted to report to work and must self-isolate for 14 days. If you experience any symptoms, you should contact the appropriate health authority to determine how to seek medical care safely.
If all of the above statements are confirmed, you may proceed to work. If you begin to experience symptoms during working hours, please report this to your manager immediately.
This is a reminder to adhere to the safe distancing rules, wear your required personal protective equipment, and practice safe hygiene.
I confirm that I have completed this form in good faith and certify that all information is true and correct to the best of my knowledge. I understand that reporting to work if I have been potentially exposed to COVID-19 poses a grave risk to the health and wellness of others.
