Please fill out the form below:

* Close Contact is defined as a person who:  
  • Has provided care for an individual (healthcare worker, family member, caregivers).
  • Has been in close physical contact with an individual without consistent and appropriate use of personal protective equipment.
  • Has lived with or had close prolonged contact (within 2 meters) with the individual while they were infectious.

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* 1. Name:

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* 2. Date

Date

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* 3. Phone Number

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* 4. Email Address

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* 5. Planned Start Date of Work Date

Date

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* 6. Customer, Producer or Roska Business Unit

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* 7. Site Location:

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* 8. Have you, or any member of your household, travelled outside of Canada in the last 14 days?

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* 9. Have you, or any members of your household, had close contact* with anyone suspected or diagnosed as having COVID-19 in the last 14 days?

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* 10. Do you have any of the following symptoms (unrelated to a pre-existing illness or health condition)
fever
cough
shortness of breath/difficulty breathing
runny nose
sore throat
chills
painful swallowing
stuffy nose
headache
muscle or joint aches
feeling unwell, new fatigue or severe exhaustion
gastrointestinal symptoms (i.e. nausea, vomiting, diarrhea or unexplained loss of appetite
loss of sense of smell or taste
conjunctivitis, commonly known as pink eye
If Yes then contact your local health authority for immediate direction.

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* 11. Are you currently being investigated as a suspected case of COVID-19?

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* 12. Have you tested positive for COVID-19 within the last 10 days?

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* 13. Will you be Travelling for business purposes for or on behalf of Roska (see note below)?  Please answer the following questions and submit for approval prior to departure.  
NOTE: the following section is only applicable if you will be flying or if you will be travelling more than 5 continuous hours by ground.

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* 14. Is it a priority for you to travel or can the work be done at your current location?

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* 15. Are you flying or driving? (trips less than 8 hrs by ground, workers are encouraged to travel by vehicle)

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* 16. Will travel be inside or outside of your home province? 

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* 17. Will you be making multiple stops on your commute? (If yes, the risk for contraction of COVID-19 is much higher)

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* 18. How long will you be staying at your travel destination?

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* 19. How many people will you be in contact with at the Roska locations?

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* 20. Do people in your household have increased contact with the general public? (i.e. service or health care workers)?

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