50px

COVID-19 Symptom reporting form

75px

Bloc formulaire

The Public Health Agency of Canada (PHAC) assesses a real public health hazard associated with COVID-19 for Canada.

To this end, Les Entreprises A&R Brochu (Const.) Inc. must take preventive measures to ensure the health and safety of all its employees, visitors and their entourage as well as the work environment at 1505 rue Marie-Victorin in Saint-Bruno-de-Montarville.

We ask you to answer this questionnaire in order to assess that your presence is safe for the project and to submit this form to the Health and Safety (OHS) manager, or to the superintendent.

Anyone present at the site must fill out this form every day before the start of their working day.

Fields marked with an asterisk are required.

First name *

Last name *

E-mail adress *

Phone number *

You're a : *

Select the reason of your presence

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

Do you currently have the following symptoms: fever, cough, sudden loss of sense of smell, or breathing difficulties *

Have you been exposed to a person who has a confirmed or probable case of COVID-19 infection? *

Do you confirm that the information you have entered in this form is true? *

100px

A&R Brochu Construction

COVID-19 Symptom reporting form