Have you reviewed the Government of Canada’s COVID-19 prevention and risk site:

https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevention-risks.html?topic=tilelink

1. 
Are you following COVID-19 Health and Safety protocols by Public Health (PPE, Social distancing etc.)?

2. 
Are you working in a facility?

3. 
Are you working with any other client/s right now?

  • If yes, is it a private residence? ___________
  • Is the person/ family exposed to COVID-19?______________________________
  • Are you working with another agency aside from Arcadia Home Care?________________

4. 
Do you have any roommates or family members living with you?

5. 
Do you have any children living with you?

  • If yes, are your children going to daycare or school?__________
  • Have your children, family members roommates exhibited any symptoms (fever, cough, shortness of breath) related to COVID-19?________
  • Has anyone in your household been diagnosed of COVID-19 in the past 1 month?_________________________

6. 
Do you have any roommates/family members/children/friends visiting you?

7. 
Do you live in an apartment building?

8. 
Do you travel in the elevator alone or leave the elevator when others get in?

9. 
How do you travel to your client? (Uber, Lyft, Transit, etc.)

10. 
If by your own vehicle, please answer the question(s) below:

  • Do you share your vehicle with anyone else? If yes, please answer the question(s) below:________________________
  • Do the person(s) who shares the vehicle live with you? ______________
  • Do you or the person who shares your vehicle transport anyone other than in your household?__________________________

11. 
Have you travelled outside Canada in the past 2 weeks?

12. 
Have you met with a family member who travelled outside of Canada in the past 2 weeks?

13. 
Have you interacted with a family member or friend who is person under investigation or confirmed COVID-19 positive result?

14. 
Have you been diagnosed with COVID -19? If yes, when and were you given clearance by Public Health to work?

15. 
Other relevant information that you want to disclose

16. 
Name

17. 
Date