Health and Safety Covid Sign-in Step 1 of 4 25% Your Location*FENMARFIMA COVID-19 QUESTIONNAIRE Please fill out the complete health questionnaireName*Personal Phone Number*Company Self-Declaration We ask that you please answer the following questions truthfully for your safety and the well-being of our construction site Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions. Fever and/or Chills Shortness of Breath Difficulty Swallowing Pink Eye Conjunctivitis Headache Muscle aches Cough or Barking Cough (croup) Sore Throat Decrease or loss of smell or Taste Runny or stuffy/congested nose Digestive issues like nausea/vomitting, Diarrhea, Stomach pain Extreme Tiredness Symptoms Declaration*YesNoHas a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home?)?*YesNoIn the last 10 days, have you tested positive on a rapid antigen test or home base self-testing kit? If you have since tested negative on a lab-based PCR test, select “No”*YesNoIn the last 14 days, have you had close contact with or cared for someone diagnosed with COVID-19? If you are fully vaccinated* and have not been advised to self-isolate by public health, select “No”. Fully vaccinated is defined as a individual ≥14 days after receiving their second dose of a two-dose of a two-dose COVID-19 vaccine series of their first dose of a one-dose COVID-19 vaccine series.*YesNoIn the last 14 days, have you received a COVID alert exposure notification on your cell phone? If you already went for a test and got a negative result answer “NO”*YesNoIn the last 14 days, have you travelled outside of Canada and been advised to quarantine per the federal quarantine requirements?*YesNoAre you unvaccinated and in the last 14 days someone you live with travelled outside of Canada AND has been advised to quarantine per the federal quarantine requirements?*YesNoIs anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?*YesNo Entry not Allowed NOTE : While on-site you must always adhere to all posted health and safety guidelines. If the answer is “yes” to any of the questions, access to the facility will be denied. Any questions should be directed to email@example.com By agreeing, I acknowledge that all information provided on this intact form is accurate and I have agreed to follow the policies and procedures put in place by CRSC and the customer upon entering the property*I AgreeI DisagreeSignatureDate APPROVEDEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.