Contractor Screening Form COVID-19

The health and safety of our customers and employees is important at the Township of North Dumfries. As such, prior to any on-site or project implementations, this form must be completed by on-site contractors and each of their employees each day prior to entering the building regarding their current health. Our primary goal is to prevent the spread of the COVID-19 virus.

Contractor Name

Company Name

Date of on-site visit

Have you travelled outside of Canada in the last 14 days?

Yes

If you answered YES to travelling outside of Canada in the last 14 days, where did you go and what were the dates?

Are you currently experiencing any of the following new symptoms?

Fever

Cough

Sore Throat

Difficulty swallowing

Difficulty breathing or shortness of breath

New olfactory or taste disorder(s)

Nausea/vomiting, diarrhea, abdominal pain

Runny nose or nasal congestion

No symptoms

If you answered yes, but do not think the symptoms are related to COVID-19, please explain your symptoms below.

Have you been advised by the Public Health Authority or your family physician to self-monitor or self-isolate in the last 14 days?

Yes

Have you been in contact with someone who has made you aware they tested positive for COVID-19 or been in contact with a person who tested positive for COVID-19 within the past 14 days?

Yes

North Dumfries reserves the right to refuse for our employees to deliver on-site support based on the information provided above. If any of the above answers is a YES or you are experiencing any of the above symptoms, the contractor is not permitted to enter the Township facility for 14 days. If the status of your health changes over the course of working with the Township or if you have any questions, please notify Julianne Gale at 519-632-8800 ext. 111.

Enhanced Screening for Contractors

All contractors must provide the Township of North Dumfries with a copy of their COVID-19 Health and Safety Protocols prior to commencing work at the Township of North Dumfries properties and facilities.
Contractors must enter/exit through a designated entrance/exit only.
All contractors must sign in/out when on site.
If any contractor or employee develops flu-like symptoms, they must immediately leave, self-isolate, and contact the project supervisor by phone and seek medical guidance. The municipal Site Supervisor must be notified immediately.

The Township of North Dumfries as the Prime Contractor will:

Ensure that no more than one contracting company will be in a specific area of the facility. If the contractor or their staff need to go outside that area, they must ask permission of the Township supervisor.
At all times while performing a work process in our facility, contractors and their staff must maintain a 2-metre (6 feet) distance. If this cannot be maintained, a risk management protocol must be established and followed. Please share protocol with the project coordinator.
Everyone on-site needs to know where to access soap and water or hand sanitizer.

Facility Location

Municipal Site Supervisor Name

Municipal Site Supervisor Signature

Clear

Phone number

Employee/Contractor Signature

Clear

Date

A healthy and safe workplace is everyone’s responsibility. Your active participation and support are vitally important to maintaining and improving health and safety in our workplace.