Daily Pre-Jobsite COVID-19 Health & Safety Check
Section A - Instructions:
*Employees must complete the Daily Pre-Jobsite COVID-19 Health & Safety Check before coming to the Shop or going to the site!

Section B - Disciplinary Actions:
A violation of the company's Occupational Health and Safety policy may result in ANY of the following disciplinary actions:
1. Verbal Or Written Warning
2. A Written Warning
3. 1 Day Suspension
4. 1 Week Suspension
5. Immediate Dismissal

Section C:
(1) If you have any of the COVID-19 related symptoms such as fever, dry cough, shortness of breath, headache, aches/pains, soar throat, fatigue, or you disagree with this-screen-process and Integrity's COVID-19 Pandemic Protocol, then you have automatically failed the screening and cannot enter the site. You will be advised on the next steps, including either contacting the local public health or telephoning Telehealth Saskatchewan for further instructions:
(2) Call Health-Line 811 if you have recently travelled and are experiencing respiratory or flu-like symptoms, or
any non-health related inquiries related to COVID-19 call toll-free 1-855-559-5502 from 8 a.m. to 5 p.m. daily.
(3) Staff at the Federation of Sovereign Indigenous Nations are available to answer questions you or your First Nation community may have that doesn't require legal, medical or counselling advice. The toll-free number at 1-888-833-8885 offers information from 9 a.m. to 9 p.m. daily.
(4) At the Site: Group Size/Separation/Social Distancing
Avoid handshakes.
Maximize social distancing during work activities and during any breaks.
Keep group sizes small – fewer than 8 people in any gathering/meeting when possible.
Minimize activities where groups of workers congregate including work areas, eating areas and designated smoking areas.
(5) Personnel/Workers who do not present a risk of COVID-19 transmission to others on-site will be allowed to enter the site after they have sanitized their hands.
(6) Each day site-supervisors should monitor at the start of shift that their workers are healthy, fit for work, and, to the best of their knowledge free of any symptoms or restrictions associated with COVID-19 at the jobsite.
(7) Supervisor should verify at the end of shift that their workers are healthy, fit for work, and to the best of their knowledge free of any symptoms or restrictions associated with COVID-19 at the jobsite. The supervisor, through asking questions or observations, can do this.

Section D: Declaration:
I acknowledge that I have read, and do hereby accept the terms and conditions contained in this form. I solemnly swear that I have completed this form truthfully and affirm as follows:
(1) Before coming to work today, I was not experiencing flu-like symptom (e.g. fever, headache, body aches, cough, difficult breathing).
(2)  Before coming to work today, I wasn't in close contact with a person showing symptoms or tested positive for COVID-19.
(3) If I feel ill during the day, I will contact the health care provider immediately, notify the immediate supervisor immediately, and strictly follow the instruction given to me by the supervisor.
(4) I have not been in close contact with a person with acute respiratory illness who has been outside of Canada in the last 14 days.
(5) I wash my hands frequently enough (before and after breaks, lunch, meetings, or using the bathroom), and wash the hands for at least 20 seconds each time in accordance with INTEGRITY COVID-19 Pandemic Protocol.
(6) The hand sanitizer and/or sanitizing wipes are available in the work area and I use them when entering and leaving the work area. If sanitizer or wipes are out, I will notify the supervisor immediately.
(7) I have the proper protective equipment (PPE) (mask, gloves, safety glasses or safety shield and they are clean. When the PPEs are out, I will notify the supervisor immediately.
(8) As per the Saskatchewan Employment Act and applicable OH&S Regulations, I have 'Rights to know', 'Rights to participate' and 'Rights to Refuse the Dangerous Work'.
(9) I will self-isolate for at least 14-days upon return from the travel, including any cruises, any communities (inside Saskatchewan and/or outside the province) with an increasing rate of community-related transfer of COVID-19, regardless of symptoms being present.
Sign in to Google to save your progress. Learn more
Full Name: *
Company Name *
Your Contact Cell# *
Email (Optional):
Today's date *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy