COVID-19 Health Screening Declaration

IN THE PAST 14 DAYS, HAVE YOU OR ANYONE IN YOUR HOUSEHOLD HAD:

Sudden onset of respiratory illness (congestion, nasal drainage, difficulty breathing)?*

Fever (temperature greater than 37.6° C or 99.68° F)?*

Cough or sore throat?*

Have you had contact with someone who has a confirmed or suspected case of COVID-19?*

Have you or anyone in your household traveled to an impacted area or used a high-risk type of travel in the past 14 days?*

Please confirm the below:*

I confirm that the above information given is correct.
I understand that if the answer is “Yes” to any of the questions above, additional information may be required before I can access the office or enter a jobsite.
I also understand that if I am a repeat visitor to the office or jobsite, I must report any change to my answers above to Human Resources before arrival.

Name*

Project Name / Address*

Date(s) Visiting the Office/Site*

Name of the Conwest employee(s) you are coming to visit*

Your Company's Name*

Cell Phone/Email*

*

I agree

By completing this form, you are consenting to the collection of personal information by Conwest. This information is being collected to ensure the health and safety of our employees and to comply with the recommendations of the Provincial Health Officer (PHO) to protect against the spread of COVID-19. This information will be collected and kept secure by Human Resources and may be reviewed by the applicable project manager, and/or Project Superintendent, and then kept secure by Human Resources. and will not be disclosed to any third party without your consent other than to the PHO upon request or as otherwise authorized pursuant to BC’s Personal Information Protection Act. Your information will be destroyed after 30 days unless it was properly disclosed to a third party or Human Resources reasonably determines it is required to assist in tracing any COVID-19 exposures.