COVID-19 Site Access Health Assessment
This form should be completed (electronic submissions preferred) by participants in TUC events and programs prior to accessing a project or work site.

In situations where it is impractical to complete this form, it is acceptable to pre-screen individuals verbally using the Site Access Health Assessment form as a guide.

Participants whose visit or work on site extends for more than one consecutive day are required to complete the Assessment prior to the first day of their visit or work and when returning for any subsequent visits or work.
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Name
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Self-Assessment Questionnaire
In the past 14 days have you returned from travel to any locations outside of Canada?
Clear selection
In the past 14 days have you had close contact with someone who has traveled to locations outside the country?
Clear selection
In the past 14 days have you had close contact with someone who has traveled to locations that are under the travel restrictions listed by the Government of Canada? https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/latest-travel-health-advice.html
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In the past 14 days have you had close contact with someone who is confirmed as having COVID-19?  Close contact is defined as: 1) close physical contact with a person while they were infectious without consistent and appropriate use of PPE; 2) Lived with or otherwise had close prolonged contact (within 6 feet) with a person while they were infectious; 3) Direct contact with infectious bodily fluids of the person (e.g. was coughed or sneezed on) while not wearing recommended PPE.
Clear selection
Do you have any of the following? Fever, cough, shortness of breath, difficulty breathing, sore throat, runny nose.
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*If you answered YES to any of the above questions contact your local Health Information Line and please do not go to a TUC worksite.
If you answered NO to all of these questions please submit a completed request form to TUC to review.
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