Daily Screening Health Declaration

All staff and visitors must complete this form upon arrival.

The information collected is in compliance with the advice, recommendations and instructions issued by the Office of the Chief Medical Officer of Health on screening individuals and will be used only to verify compliance, and for no other reason. By completing this form and entering the premises you are expressly consenting to such collection and use

Name

First Name

Last Name

Enter your primary contact number:

(###)

###

####

Please identify the company you work for/are visiting:

Royal LePage Commercial Westhaven

Westhaven Group

Guest or Essential Visitor (incl. delivery, maintenance, or contract workers)

I declare and agree that:

I have none of the following or worsening symptoms of COVID-19 (symptoms should not be chronic or related to other known or caused conditions): fever or chills, difficulty breathing or shortness of breath, cough, sore throat, trouble swallowing, running nose/ stuffy nose or nasal congestion, decrease or loss of smell or taste, nausea, vomiting, diarrhea, abdominal pain, not feeling well, extreme tiredness, sore muscles

I have not been in close contact with anyone with a known (has tested positive) or probably (as determined by a health official) case of COVID-19.

I have not travelled outside of the country in the past 14 days

I have not been in contact with anyone who has traveled outside of the country in the past 14 days.

I have not within the past 14 days been directed by Public Health to self-isolate.

I acknowledge that if I have not agreed to all of the items in question 4, I will not enter the office premises and must contact my Manager or Broker of Record. If a guest or essential visitor, I will advise my business contact. If I experience any symptoms related to COVID-19, I will contact the appropriate health authority to determine how to safely seek medical care. I acknowledge that if I have agreed to all of the items in question 4, I may enter the office premises. If I begin to experience symptoms related to COVID-19 while in the office premises or should any of my responses to question 4 change, I will immediately report this to my Manager or Broker of Record. If a guest or essential visitor, I will advise my business contact. I acknowledge that I will adhere to all of the safety guidelines put in place by the company, including adherence to the safe distancing rules, wearing a mask / face shield or other required personal protective equipment, and practicing safe hygiene

I Agree