The safety of our employees, customers and the community is the top priority for Epoxy & Cie Canada and Chemtec. In the current context where COVID-19 - the coronavirus - continues to spread globally, Epoxy et Cie Canada and Chemtec are continually monitoring the situation and will take all reasonable precautions to protect its employees, customers and the community.

To help prevent the spread of COVID-19, we use a basic screening questionnaire for everyone who may have been exposed to someone with COVID-19. Your participation is required to help us implement preventive measures that will protect you and other individuals in your work environment.

Name *

Email *

Date *

1. In the past 14 days, have you returned from a trip to any of the following countries? South Korea, Iran, Italy, Singapore, Japan, Hong Kong, Germany, Spain *
YesNo

2. Have you been in contact (or physically close) with someone who has traveled, in the past 14 days, to any of the following countries? South Korea, Iran, Italy, Singapore, Japan, Hong Kong, Germany, Spain *
YesNo

3. Have you traveled OUTSIDE of Canada in the past 14 days? *
YesNo
If yes, please specify your date of return to Canada

4. Have you traveled OUTSIDE your home province in the past 14 days? *
YesNo
If yes, please specify your date of return to your province

5. During the past 14 days, have you had close contact with someone who has been diagnosed with (or cared for) coronavirus? *
YesNo
If yes, please provide more details

6. Are you CURRENTLY experiencing 2 or more symptoms of a cold or flu (fever, cough, difficulty breathing)? *
YesNo

7. Have you been on a cruise ship in the past 14 days? *
YesNo

8. Please list all the places you have traveled to in the last 14 days, including stopovers during transport *

9. Have you been in contact with someone who has become ill or exhibited symptoms of COVID-19 after returning from an international trip? *
YesNo
If yes, please describe the nature of contact

10. Have you been in direct contact with someone tested for COVID-19? *
YesNo
If yes, please describe the nature of contact

11. Have you recently visited a healthcare facility where a positive case of COVID-19 has been confirmed in the past 14 days? *
YesNo
If yes, please specify if you have been contacted by public health regarding a potential exposure

12. Are you vaccinated ? *
YesNo
If yes, how many doses did you receive ?

13. Are you able to bring your proof of vaccination ?
YesNo

The fieds with * symbol are required