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Consent Form Covid 19

This document is a COVID-19 questionnaire that must be completed daily by employees before entering the office. It asks whether the employee is experiencing any COVID-19 symptoms and if they have traveled or been in contact with someone who may have COVID-19. By completing the questionnaire, the employee consents to the company storing and sharing their health information as needed to maintain workplace safety during the pandemic.

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Mahesh with Usha
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50 views1 page

Consent Form Covid 19

This document is a COVID-19 questionnaire that must be completed daily by employees before entering the office. It asks whether the employee is experiencing any COVID-19 symptoms and if they have traveled or been in contact with someone who may have COVID-19. By completing the questionnaire, the employee consents to the company storing and sharing their health information as needed to maintain workplace safety during the pandemic.

Uploaded by

Mahesh with Usha
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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COVID-19 Questionnaire

The COVID-19 Questionnaire must be completed and submitted daily before you reach the office.
If you are ill, or experiencing symptoms listed below, please stay home and contact your health professional for
advice on whether you should be tested for COVID-19.

Are you currently experiencing any symptoms specifically related to a cold or flu?
☐ Yes ☐ No

Have you experienced any of the symptons related to COVID-19? (check those that apply)
☐ Fever (equal or greater to 38C) ☐ Sneezing (not allergy related)
☐ Chills ☐ Runny nose/congestion (not allergy related )
☐ Cough (new or worsening) ☐ Headache
☐ Shortness of breath or difficulty breathing ☐ Muscle aches
☐ Sore throat ☐ Digestive issues (nausea, diarrhea)
☐ Difficulty swallowing ☐ Loss of taste or smell
☐ Confusion ☐ Loss of consciousness

Have you travelled outside of the country in the last 14 days? ☐ Yes ☐ No

Has someone in your household travelled outside of Canada in the past 14 days? ☐ Yes ☐ No

To your knowledge, have you had close contact with anyone that has or may
have COVID-19? ☐ Yes ☐ No

I feel healthy and intend to be in the office today. ☐ Yes ☐ No

Consent to Disclose Personal Health Information

I, ____________________________, authorize The PEER Group Inc. to collect, store and divulge
(Print your name)
information related to my health status as related to COVID-19. I understand that this information will be stored
on PEER’s network for up to 3 years after COVID-19 State of Emergency ends. I understand that this information
will be shared with the Health & Safety Committee, PEER Group Directors, Public Health and/or hospital officials as
required to maintain a safe and healthy workplace and community.

I agree that the Health & Safety Committee or PEER Group Directors may notifiy the company at large if I contract
COVID-19 or come into contact with someone with COVID-19 so they can take the appropriate protective
measures. ☐ Yes ☐ No

Employee Signature: ___________________________ Date: _______________________

\\PEERGROUP.COM\FILES\ADMINISTRATION \COVID-19\HEALTH TRACKING EMPLOYEE FORMS\PEER GROUP CONSENT FORM COVID


VER.2.DOCXPEER GROUP CONSENT FORM COVID VER.2

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