Covid-19 Pre-Work Screening Tool | Great Lakes Copper Ltd.

Name*

First Last

Person I report to directly (Group Lead, Supervisor, Manager etc.)*

Working Hours*

Have you travelled outside Canada in the last 14 days?*

I have NOT travelled outside Canada in the last 14 days
I HAVE travelled outside Canada in the last 14 days

Do you have any symptoms associated with COVID-19? (These include fever, chills, difficulty breathing, shortness of breath, cough, sore throat, trouble swallowing, runny nose, stuffy nose, nasal congestion, loss/decrease of smell, loss/decrease of taste, nausea, vomiting, diarrhea, stomach pain, tiredness, headache, pink eye, sore muscles and a general unwell feeling)*

I do NOT have any of the above symptoms
I DO have one or more of the above symptoms

Have you been exposed to someone with a confirmed or probable case of COVID-19?*

I have NOT been exposed to someone with a confirmed or probable case of COVID-19
I HAVE been exposed to someone with a confirmed or probable case of COVID-19

Is a member of your immediate household awaiting a COVID-19 test or test result, unless the tests are to attend a long-term care facility or is a pre-surgery requirement?*

NO, no-one in my immediate household is awaiting a COVID-19 test or test result (unless the tests are to attend a long-term care facility or is a pre-surgery requirement?)
YES, someone in my immediate household is awaiting a COVID-19 test or test result (unless the tests are to attend a long-term care facility or is a pre-surgery requirement?)