covid

COVID-19 Pre-Screening Form

Due to the recent concerns related to the COVID-19 virus, Capital Electric respectfully requires all persons requesting entry to the site to complete the following questionnaire prior to being permitted access.

* Indicates required field

Date *

Name *

First

Last

Company *

Email *

Current Symptoms

Please check each box indicating which symptoms you are currently experiencing.

Age & Risk Levels

Any person of age 70 years or older is permitted access to the site if they are an essential worker, but are made aware of the elevated risk levels.

Are you of the age 70 years or older? *

Yes No

Travel

Any person who they themselves, or someone they are living with, has returned to Canada or Ontario within the last 14 days will not be permitted access to the site and is required to self-isolate for 14 days from the date of return.

Have you or someone you are living with returned to Canada or Ontario within the last 14 days? *

Yes No

Direct Contact

Any person who has had confirmation of direct contact with a confirmed positive COVID-19 will not be permitted access to the site; and is required to self-isolate for minimum of 14 days from the date of contact. Prior to returning to site, the person must have been symptom free for at least 10 consecutive days.

Have you had direct contact with a confirmed positive COVID-19? *

Yes No

Symptoms

Any person who is living with someone who is showing symptoms but they themselves are not showing symptoms, will not be permitted to access the site and is required to self isolate for a period of 14 days. Any person who they themselves have developed symptoms of COVID-19 will not be permitted access to the site; and is required to self-isolate for a minimum of 14 days. Prior to return, the person must complete the 14 day self-isolation and be symptom free for 10 consecutive days. A note from a physician may be considered for early return in rare circumstances.

Yes Symptoms = Fever, Cough, Shortness of Breath, Body Aches, Extreme Fatigue, Sore Throat, Headache, Diarrhea, Vomiting, Loss of Sense of Smell.

Have you, or someone you live with, developed COVID-19 symptoms? *

Yes No

Positive Test

Any person who has tested positive for COVID-19 will not be permitted access to the site for a minimum of 14 days after the first sign of symptoms or the date of the positive test (if the test had been done prior to symptoms); and will not be able to return until they have reached the minimum 14 day isolation period, have been cleared by a negative test result and have been symptom free for at least 10 consecutive days.

Have you been tested positive for COVID-19? *

Yes No

Submit