Covid-19 Declaration Form

Operating location (region):
—Please choose an option—WindsorTorontoOther

1) Have you traveled outside of Canada in the last 14 days? (Answer "no" if you are exempted from federal quarantine as per Group Exemptions, Quarantine Requirements under the Quarantine Act).
YesNo

[group travel-no]
2) Are you currently experiencing any of the following symptoms? Select yes if these symptoms are new or worsening. Select no if these symptoms are chronic or related to a previously known condition.

• Chills

• Cough

• Fever / high temperature

• Shortness of breath

• Decreased or loss of smell or taste

• Sore throat

• Difficulty swallowing

• Pink Eye

• Runny, stuffy, or congested nose

• Headache

• Nausea, vomiting, diarrhea, stomach pain

• Muscle aches

• Extreme tiredness

• Falling down often

YesNo
[/group]

[group symptoms-no]

3) In the last 14 days, have you been identified as a close contact* of someone who currently has COVID-19? (*Close contact means, a) being less than 2 metres away in the same room, workspace, or area for over 15 minutes without you and the COVID-19 positive individual wearing masks during the exposure, or b) living in the same home).

YesNo

[/group]

[group contact-no]

4) Has a doctor, health care provider, or public health unit told you that you should currently be in covid isolation?

YesNo

[/group]

[group isolation-no]

5) In the last 14 days, have you received a COVID-19 Alert exposure notification on your cell from the COVID Alert app? (Answer “No” if based on the alert you went for a test and got a negative result, and you were not advised to self-isolate).

YesNo

[/group]

[group alert-no]
I declare that I have met the Covid Safety standards by truthfully answering NO to the above questions, and am safe to continue working.
[/group]

[group any-yes]
I declare that I may have contracted or may be at risk for developing Covid-19 and am not eligible to continue working at this time.

[/group]

KMJ will use the information you provide for the purpose of providing you access to facilities and work sites, for management of business operations, and for processing your leave.

NOTE: Please contact your local HR office regarding questions about the KMJ Privacy Statement.

Please view our Covid-19 Safety Plan for actions and guidelines.

Uncheck this box if you are human.