Facilities Management

Facilities Management

COVID-19 Toolbox Signing Form

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Information

Date

Name

Shop

Supervisor or Leadhand

COVID-19 Health Check

Are you required to self-isolate due to direction from Public Health?

Yes No

Do you have any of the following symptoms (new or worsening)?

Fever (Including chills and sweats)
Runny, stuffy, Congested Nose
Loss of appetite
Vomiting or Diarrhea for more than 24 hours
Cough

Loss of sense of smell or taste
Unusual fatigue, lack of energy
Shortness of Breath or difficulty breathing
New onset of muscle aches
Sore throat or Difficulty swallowing
Headache

Yes No

If you answered yes to any of the above questions, please contact your supervisor immediately to advise and discuss.

COVID-19 Safety Reminders

Wash your hands.
Avoid touching your face.
Stay at least 6 feet apart.
Clean and disinfect frequently touched surfaces.
Don’t forget to review the COVID-19 FAQ’s they are on your Ipad.

I acknowledge that I have reviewed the safety reminders