COVID-19 Survey - Aim Lock and Safe

At Aim Lock & Safe Ltd. Our focus is on helping to keep our employees healthy. With the rising case count, we are required to perform the following pre-screening.

Please answer the following questions honestly, and to the best of your knowledge. Once you have completed this checklist, please sign and return to our office via email [email protected]
Do you, or anyone who will be in contact with our technician have any of the following symptoms or signs?
New or worsening cough
YES No
Shortness of breath
YES NO
Sore throat
YES NO
Runny nose, sneezing or nasal congestion
YES NO
Hoarse voice
YES NO
Difficulty swallowing
YES NO
New smell or taste disorders
YES NO
Nausea, vomiting, diarrhea, abdominal pain
YES NO
Unexplained fatigue
YES NO
Chills
YES NO
Headache
YES NO
Have you travelled outside of Canada or had close contact with anyone that has travelled outside of Canada in the past 14 days?
YES NO
Do you have a fever?
YES NO
Have you had close contact with anyone with respiratory illness or confirmed or probable case of COVID-19?
YES NO

Thank you for taking the time to complete our questionnaire. If your answer to any of these questions changes at any point please inform our office ASAP.

If you answered NO to all of these questions, we would be happy to proceed with scheduling your service request. Please take note of the following protocols that we are asking you to adhere to while our technician is performing on-site service.
- You will be required to wear a mask at all times while interacting with our technician. If you are unable to do so due to health exemptions, you are asked to maintain a 6 foot distance between yourself and our technician.
- For the foreseeable future, we will not be collecting work order sign-offs, or using customer phones or devices for checking in and out on site in order to limit touch contact.
- By law, our technicians have the right to refuse unsafe work environments. If while on site, our technician feels that they are unsafe or at risk, they have been instructed to leave site immediately, and report to our office.
If you answered YES to any of these questions, unfortunately due to the risk level for our technicians, we are required to adhere to a 14 day waiting prior before we can schedule your service call. Alternatively, if you are able to provide our office with a negative COVID-19 test result from the last 72 hours, we would be happy to proceed with scheduling.

We apologize for any inconvenience that this may cause, and thank you for helping to keep us all healthy and safe.

Name
Company Name
Email
Phone
Signature
Date
MM slash DD slash YYYY
We are committed to maintaining the accuracy, confidentiality, and security of your personally identifiable information ("Personal Information"). As part of this commitment, our privacy policy governs our actions as they relate to the collection, use and disclosure of Personal Information. Our privacy policy is based upon the values set by the Canadian Standards Association's Model Code for the Protection of Personal Information and Canada's Personal Information Protection and Electronic Documents Act.

The information in this questionnaire is for the purpose of the Health & Safety of our employees only. For more information on our Privacy Policy, please visit our website at www.aimlockandsafe.ca.

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