Visitor and Employee Self Declaration Form The safety of our employees, customers, families and visitors remains our overriding priority at Electric Motor Service Limited. As the coronavirus disease 2019 (COVID-19) outbreak continues to evolve and spread globally, we are monitoring the situation closely and will periodically update company guidance based on current recommendations from Heath Canada, the Center for Disease Control and the World Health Organization. To prevent the spread of COVID-19 and reduce the potential risk of exposure to our employees and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time Employee/Visitor Name: Email: Personal Phone Number (mobile/home): Visitor’s Company/Organization: Name of EMSL Representative: EMSL Location: Self-Declaration by Employee/Visitor Are you feeling well today? YesNo Have you had close contact* with or cared for someone diagnosed with or showing symptoms of COVID-19 in the last 14 days? YesNo *Close contact is defined as: a) being within approximately 6 feet (2 meters) of a COVID-19 case for a prolonged period of time; close contact can occur while caring for, living with, visiting or sharing a healthcare waiting area or room with a COVID-19 case – or – b) having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on) Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)? YesNo Current body temperature: °F *If it is deemed by a supervisor or manager that you may have a fever you must self-assess before starting work or being admitted to the site. SIGNATURE (VISITOR): DATE:
