COVID-19 Self-Assessment | Fidelity Engineering & Construction

1-888-468-5768 - FAX: 905-355-2555 admin@fidelityeng.com

Facebook
Google

Facebook
Google

HOME
WHAT WE DO
CONTACT US
CAREERS
ABOUT US
- HEALTH & SAFETY
LANDSCAPE YARD

Select Page

COVID-19 Self-Assessment

To ensure everyone’s safety at Fidelity, we have implemented a COVID-19 Self-Assessment form. This form is MANDATORY before coming onto ANY Fidelity site.

Please fill out the form below before entering a Fidelity site.

Thank you for your cooperation in keeping our Fidelity sites safe for our contractors, employees and all visitors.

Name *

First

Last

Company Name *

Phone Number (no spaces) *

Email *

1. Are you currently experiencing one or more of the symptoms below that are new orworsening? Symptoms should not be chronic or related to other known causes or conditions. *

Fever or chills (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher)
Difficulty breathing or shortness of breath (Not related to asthma or other known causes or conditions you already have)
Cough or barking cough [croup] (Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)
Sore throat (Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have)
Difficulty swallowing (Painful swallowing not related to other known causes or conditions you already have)
Runny or stuffy/congested nose (Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have)
Decrease or loss of smell or taste (Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have)
Digestive issues like nausea/vomiting, diarrhea, stomach pain (Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have)
Pink eye (Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have))
Headache (Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)
Muscle aches (Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have)
Extreme tiredness (Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)
Falling down often (For older people)
I feel well and am not experiencing any symptoms listed above

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

Yes
No

3. In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19? *

Yes
No

4. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?If you already went for a test and got a negative result, select "No." *

Yes
No

5. In the last 14 days, have you or anyone you live with travelled outside of Canada? If you or anyone you live with are exempted from federal quarantine as per Group Exemptions, Quarantine Requirements under the Quarantine Act, select “No”. *

Yes
No

6. Is anyone you live with currently experiencing any new COVID-19 symptomsand/or waiting for test results after experiencing symptoms? *

Yes
No

HOME
WHAT WE DO
CONTACT US
CAREERS
ABOUT US
LANDSCAPE YARD

Facebook
Google

Designed by Elegant Themes | Powered by WordPress