ESG

COVID-19 Precautionary Screening – Health Questionnaire

As we continue to monitor COVID-19, we are conducting active screening for potential risks of COVID-19 with everyone entering the SMG camp & worksite. We are asking all personnel (SMG & contractors) to declare the following:

 

Name: ……………………………………………………………………………….

Date: ………………………………..……………………..…….…….…………….

Company: …………………………………………………………………………

Signature: …………………….……..…………………….…….…….………….

 

Have you returned from an international location (including the United States) in the last 14 days?

  • YES
  • NO

Do you have (or had in the last 7 days) any flu like symptoms?

  • Fever / chills
  • Headache
  • Sore throat
  • Fatigue
  • Muscle or body aches
  • Cough
  • Difficulty breathing
  • Nausea, vomiting or diarrhea
  • Loss of taste, smell or appetite
  • Running nose or sneezing
  • NO

Are you taking any medication including over the counter medications such as Tylenol or Advil to treat or suppress any of the above symptoms?

  • YES
  • NO

If yes, is it related to allergies?

  • YES
  • NO

Have you had close contact with a confirmed or probable COVID-19 case?

  • YES
  • NO

Are you the subject of a provincial/territorial or local public health order?

  • YES
  • NO

If yes, please explain:

 

 

 

NOTE: if you respond YES to any of these questions, or refuse to answer, then you have failed the screening and cannot enter the camp or work site.  Please contact your supervisor, site contact or doctor to complete a follow up assessment.

 

Assessment (to be completed by SMG nominated person)

 

Temperature Check:…………………………….........................................................................................................

 

Fever:

  • YES
  • NO

 

Click here to download the Health Questionnaire

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