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COVID-19 Symptom Reporting Form - Atikokan

Questions marked with a * are required

In order to control the spread of COVID-19 as well as prevent potentially symptomatic individuals from accessing Resolute Forest Products facilities, all employees, visitors and external suppliers must complete the COVID-19 Symptom Reporting Form prior to or upon their arrival at a Resolute site

Please provide your name

Please provide your phone #

Are you experiencing any of the following symptoms?

Fever ≥ 38º C / 100.4º F

Cough (new / worse)

Difficulty breathing (for example, struggling for each breath, cannot hold breath for more than 10 seconds)

Sudden loss of smell

Severe chest pain

Extreme fatigue (e.g. having a very hard time waking up )

No I do not have any of the above symptoms

Do you meet any of the following conditions

Did you travel outside the country in the past 14 days AND asked to self-quarantine by the Authorities?

Have you had close contact with or are you living with someone who is currently infected by the COVID-19 virus?

Have you been in close contact with a person who currently has a fever or respiratory symptoms (for example, cough or difficulty breathing) and who recently traveled outside the country?

Are you experiencing other COVID-19-related symptoms that should be considered as per your state or provincial public health agency’s COVID-19 self-assessment tool?

No, I do not meet any of the above conditions.

Acknowledgment

I agree to comply with the measures required to protect my health and the health of my coworkers, and with the COVID-19 guidelines issued by Resolute for the workplace.

Acknowledgment

I certify that this information is correct, and I will inform my supervisor if my health status changes during the day

Acknowledgment

I understand that if I am experiencing any of the symptoms or meet one of the conditions listed above when I complete the form, I must not come to work. I must inform my supervisor or my HR representative immediately, and I must contact my local public health agency at its COVID-19 hotline OR a health care provider located in my area and follow its instructions.