AWS Questionnaire
We require you to fill out the below questionnaire to assist in determining your fitness to work during the COVID-19 pandemic to provide a safe environment for all employers/employees at Aaron Well Servicing Ltd.

The information in this questionnaire is collected under the authority of AWS and will be used and disclosed solely for the purposes of determining fitness for work during the COVID-19 pandemic. Making sure you are aware of the policies and the required cleaning practices.

Always ensure you are following protocols for hand hygiene and remember to clean all surfaces in the doghouse and crew trucks, pens, door handle, your keys, phone, computers and other personal items.  This needs to be done multiply times throughout the day.
 
If you are a visitor to our location this questionnaire must be filled out before you go on lease/doghouse.  Please make sure you follow AWS policies and practices when on location at all times.

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Name (First and Last Name) *
Date *
MM
/
DD
/
YYYY
Lease location today? *
Please type in the Company you work for? *
Do you have any of the symptom: *
Yes
No
Fever greater than 38 degrees Celsius
New or worsening respiratory symptoms NOT RELATED to seasonal or environmental allergies ex. Cough, Shortness of breath, Difficulty breathing, Sore throat or Runnny nose
New onset atypical symptopms including; Chills, aches and pains, headache, loss of sense of smell or taste?
Have you tested positive for COVID-19? *
Clear selection
Have you returned to Canada from outside the country (including USA) in the past 14 days? *
Do you live with or have had close contact (within 2 meters/6 feet) with a person with an influenza-like illness (ILI) who had travelled outside of Canada in the 14 days before their illness started, while not wearing recommended PPE at work. *
 Do you live with or have had close contact (within 2 meters/6 feet) with a person with an influenza-like illness (ILI) who had close contact with a lab-confirmed COVID-19 case, while not wearing recommended PPE. *
Have you had close contact (within 2 meters/6 feet) with a confirmed or probable case** of COVID-19, while not wearing recommended PPE. *
Have you reviewed the AWS policies posted on our website and/or in the doghouse.  By entering this location you are deeming your are safe to enter.  IF YOU HAVE NOT answered the questions above, please do not enter the location. *
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