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* 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)
               Cough
               Fever
               Shortness of Breath/difficulty breathing
               Runny nose
               Sore Throat
               Loss of taste or smell
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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