Covid-19 Occupant Health Checklist

• Conducted on

  Date

• Prepared by

• Location
  Address

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• As part of NUR Constructions Health & Safety Program and in compliance with Public Health requirements to reduce the risk of transmission of Covid-19, this checklist is mandatory for all individuals in the home/building to complete prior to workers entering the premises.

• Have you travelled outside of Canada in the last 14 days?

  Yes

  No

• Have you been in contact with someone who has travelled outside of Canada in the last 14 days?

  Yes

  No

• •Fever

  Yes

  No

• •New cough or worsening of chronic cough

  Yes

  No

• •Shortness of Breath / Difficulty Breathing

  Yes

  No

• •Sore throat

  Yes

  No

• •Chills

  Yes

  No

• •Runny nose

  Yes

  No

• •Fatigued

  Yes

  No

• •Nausea / Vomiting / Diarrhea

  Yes

  No

• •Loss of taste or smell or loss of appetite

  Yes

  No

• If you have answered yes to any of these questions, it is deemed an unsafe environment for our workers until a health assessment is completed using the Covid-19 Self Assessment tool. If directed to take a Covid-19 test, our workers can only enter the building/residence once you have been cleared by Alberta Health.

• Phone #:

• Signature:

  Sign

• *Disclaimer: In accordance with the Personal Information Protection Act of Canada (PIPA) your information will not be shared with anyone outside NUR Construction, and is used solely for the purpose of contact tracing due to the Covid-19 pandemic. Providing this information is for the health & safety of you and your household.*