Georgian Downs - Team Member Screening

In accordance with the Human Resources COVID-19 Team Member Handbook, the COVID-19 Awareness Training Webinar and the Site-Specific COVID-19 Prevention and Control Plan, screening measures play an important role in helping to prevent and control the spread of COVID-19. All team members and workers (i.e. contractors, consultants, 3rd parties etc.) are required to ask themselves the following questions prior to entering the building and confirm this action through the online webform or hardcopy form.
 
  1. Are you sick, ill and/or have any symptoms related to COVID-19?
  2. Have you had close contact with a confirmed case of COVID-19 in the past 14 days?
  3. Have you or anyone you live with travelled outside of Canada within the past 14 days?
  4. Have you been instructed by local health authorities to self-isolate due to travel or contact history?
  5. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? 
If you answer “NO” to ALL of the above questions, complete and submit this form. Once submitted, perform hand hygiene and follow the requirements outlined in the Site-Specific COVID-19 Prevention and Control Plan for building entry.
If you have answer "YES" to ANY of the five (5) questions, you must cease (i.e. stop) completing this form and do NOT enter the building. Immediately notify your manager and supervisor. You must return home immediately (avoiding public transit). You are to contact your provincial or local health authority at 1-866-797-0000 for further guidance and requirements.

*Name: Please enter your first and last name:

*Contact Information: Please enter your phone number or email:

Per Public Health, we are required to ask you for your first and last name and a phone number or an email address so that Public Health can easily and quickly get in touch with you in case you have come into close contact with a person who has contracted COVID-19. We will not use or sell your information and will only share it with Public Health if they ask us to, in which case we will take precautionary measures when transferring it to them. By providing your contact information, you understand it will be collected, used and disclosed as described above.

*Department: Please enter your Department:

Note: If you are a contractor, consultant or 3rd Party - identify your company name instead of your department

*Provide your AGCO/License Number OR Employee (Team Member) Number:

Note: If you are a contractor or consultant - please enter "N/A"
Question 1 - Are you sick, ill and/or have any symptoms related to COVID-19? The Government of Ontario has identified the following as COVID-19 related symptoms: fever or chills, difficulty breathing or shortness of breath, coughing, sore throat, trouble swallowing, runny/stuffy nose or nasal congestion, decrease or loss of smell or taste, nausea, vomiting, diarrhea, abdominal pain, not feeling well, extreme tiredness, and/or sore muscles. 
Question 2 - Have you had close contact with a confirmed case of COVID-19 in the past 14 days?
Question 3 - Have you or anyone you live with travelled outside of Canada in the past 14 days?
Question 4 - Have you been instructed by local public health authorities to self-isolate due to travel or contact history?
Question 5 - Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? For questions on this question, see: https://covid-19.ontario.ca/screening/worker/
Team members must strictly abide to noted capacities of the identified area(s), foot markings and signage. Before entering the building, all visitors must follow the posted screening protocols.
For any questions regarding the personal information you include in this survey, please review SimpleSurvey’s Privacy Policy link found: https://simplesurvey.com/canadian-hosted-survey-software/.