Contractor Pre-Screening Declaration Form COVID-19
(Created December 5, 2021) This tool has been created to minimize the risk at Feltz Design Build. Declaration must be submitted to the direct Manager, or their designate, PRIOR to entering our facilities or vehicles.
Are you exhibiting any of the following symptoms below that are new or worsening? Symptomes should not be chronic or related to other known causes or conditions.
- Fever and/or chills - Temperature of 37.8 degrees C (100 degrees F) or higher?
- Cough or barking cough (croup) - Not related to asthma, post infectious reactive airways, COPD, or other known causes or conditions you already have?
- Shortness of breath - Not related to asthma or other known causes or conditions you already have?
- Decrease or loss of smell or taste - Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have?
- (For adults 18+ years) Fatiguem lethargy, malaise, and/or myalgias- Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions they already have). If you have received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select "No."
- (For children under 18 years) Nausea, vomiting, and/or diarrhea
In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
This can be because of an outbreak or contact tracing.
In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?
If public health has advised you that you do not need to self-isolate (e.g., you are fully immunized** or have tested positive for COVID-19 in the last 90 days and since been cleared), select “No.”
In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?
If you have already gone for a test and got a negative result, select "No." If you are fully immunized** or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No."
In the last 10 days, have you tested positive on a rapid antigen test or a homebased self-testing kit? If you have since tested negative on a lab-based PCR test, select “No.”
Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?
If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.” If you are fully immunized** or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No”.
**A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series, or their first dose of a one-dose COVID-19 vaccine series (i.e., Johnson and Johnson).
RESULTS of SCREENING QUESTIONS
If answers are NO to all questions from 1 through 7, the contractor can enter our facilities or vehicles.
In the workplace, the contractor employee must continue to follow all public health and workplace control measures, including masking, maintaining physical distance and hand hygiene.
In addition to following all workplace regular control measures, if the contractor employee has received a COVID-19 vaccination in the last 48 hours and has mild fatigue, muscle ache and/or joint pain that only began after immunization, and no other symptoms, the employee must wear a surgical/procedure mask for their entire shift at work, even if not otherwise required to do so. Their mask may only be removed to consume food or drink and must remain at least two metres away from others when their mask has been removed. If the symptoms worsen, continue past 48 hours, or if they develop other symptoms, they should leave work immediately to self-isolate and seek COVID-19 testing.
If answers are YES to any questions, the contractor cannot enter our facilities or vehicles (including any outdoor or partially outdoor space).
If any of the answers to these screening questions change during the day, the contractor must inform Feltz Design Build of the change immediately and leave our premises.
Thank you. Your form has been submitted.