Please complete this Survey upon arrival for all shifts to comply with OPH survey and employment regulations. 

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* 1. First and Last Name 

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* 2. Please enter date

Date

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* 3. What Location are you at?

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* 4. Are you currently experiencing any of these issues? 

• fever and/or chills
• cough or barking cough (croup)
• shortness of breath
• sore throat
• difficulty swallowing
• decrease or loss of smell or taste
• runny or stuffy/congested nose
• headache
• nausea/vomiting, diarrhea
• muscle aches
• extreme tiredness

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* 5. 1. Has a doctor, health care provider, or public health unit told you that you should
currently be isolating (staying at home)?
2. Have you been identified as a “close contact” of someone who currently has
COVID-19 in the last 14 days?
3. Have you received a COVID Alert exposure notification on your cell phone in the
last 14 days (and have not been tested or waiting for your result)?
4. Have you or anyone you live with traveled outside of Canada in the last 14 days?*
* Not applicable if you or anyone you live with are exempted from federal
quarantine as per the Quarantine Act.
Is anyone you live with currently experiencing any new COVID-19 symptoms
and/or waiting for test results after experiencing symptoms?

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* 6. I Agree that the information I have provided is 100% accurate to the best of my knowledge.

I will wear my PPE at all times while in the contract. 

One you Check mark agree please hit submit and you are Permitted to proceed with your cleaning. 

Thank you for the time completing this and if you have any questions please email us contact@jandc.ca

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