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* 1. First and Last Name

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* 2. Supervisor Name

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* 3. Branch Location

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* 4. Do any of the circumstances below apply to you?

(Please note, "close contact" refers to being within 2 metres for a prolonged period of time, living with, caring for, being in a relationship with, etc.)

a) Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions. Symptoms do not apply if they appeared after receiving a COVID-19 vaccine within the last 48 hours

- Fever or chills ( Temperature of 37.8 degrees Celsius)
- Shortness of breath
- Cough or barking cough (croup)
- Decrease or loss of smell or taste
- Digestive issues with nausea/vomiting, diarrhea, stomach pain
- Extreme tiredness
- Muscle aches

b) In the last 14 days, have you or anyone you live with travelled outside of Canada?

If you are exempted from federal quarantine as per Group Exemptions, Quarantine Requirements under the Quarantine Act, or you are fully vaccinated against Covid, select “No”.

If you live with someone who travelled outside of Canada, see Note 2 below.

Clarification Note 2: For those workers who live with an individual who has recently traveled outside of Canada or live with an individual who is self-isolating due to a high-risk exposure, they are permitted to attend work. However, they are required to stay home except for essential reasons for the duration of the contact’s isolation period. Essential reasons include: attending school/child care/work and essential errands such as, obtaining groceries, attending medical appointments or picking up prescriptions.

c) In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19? (Please note, “close contact” refers to being within 2 metres for a prolonged period of time, living with, caring for, being in a relationship with, etc.)

If you are fully vaccinated against Covid, select “No”.

d) Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”

e) Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

f) In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?

g) Tested positive on rapid antigen or home-based test in the last 10 days?

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* 5. Terms and Conditions

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