The Public Health Agency of Canada (PHAC) is assessing the public health hazard associated with COVID-19 in Canada. Despite this, we wish to take preventive measures to ensure the health and safety of all employees and visitors, their entourage and the work environment.

We ask you to answer this questionnaire to evaluate whether your presence is safe on the project and to give this form to the Occupational Health and Safety (OHS) Manager or to the Superintendent, if no OHS Manager is assigned to the work site.

Any person present at the work site must complete this form before or upon arrival at the work site.