Name *

First Name

Last Name

Phone *

(###)

###

####

Do you or anyone in your family have any of the following new or worsening symptoms or signs in the past 7 days? Fever or chills, Runny/stuffy nose, Difficulty breathing or shortness of breath Cough Decrease or loss, of taste or smell Sore throat, trouble swallowing, Nausea, vomiting, diarrhea, not feeling well, extreme tiredness, sore muscles *

YES

NO

Have you or anyone in your group had close contact with a confirmed or probable case of COVID-19 without wearing appropriate PPE? *

YES

NO

Have you or anyone in your family have travelled outside of Canada in the past 14 days? *

YES

NO

Are you coming from another construction project of which was shut down as a result of a suspected or positive case of COVID-19?

YES

NO