The Self Declaration Form COVID-19 has become an essential tool for organizations across Canada to maintain safe environments during the ongoing pandemic. This document is typically required before entering premises, attending events, or returning to work, helping organizations fulfill their duty of care while complying with public health guidelines. The form collects critical information about an individual's current health status, recent travel history, and potential exposure to COVID-19, while respecting Canadian privacy laws and human rights legislation. It serves multiple purposes: risk assessment, contact tracing support, and documentation of individual acknowledgment of safety protocols. The form's implementation must align with both federal and provincial requirements, including specific public health orders and privacy regulations applicable in the relevant Canadian jurisdiction.
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1. Personal Information: Collection of basic identification details including full name, contact information, and any relevant ID numbers
2. Health Status Declaration: Declarations regarding current COVID-19 symptoms, if any
3. Contact and Travel History: Information about recent travel and potential contact with COVID-19 positive individuals
4. Acknowledgment of Risk: Statement acknowledging understanding of COVID-19 risks and transmission
5. Commitment to Safety Protocols: Declaration to follow required safety measures and protocols
6. Certification of Truth: Statement certifying that all provided information is true and accurate
7. Privacy Notice: Information about how the collected data will be used, stored, and protected
8. Signature and Date: Space for signature (electronic or physical) and date of completion
1. Vaccination Status: Optional section for declaring COVID-19 vaccination status when required by specific organizations
2. Test Results: Section for recording recent COVID-19 test results if testing is part of the protocol
3. Medical History: Additional health information relevant to COVID-19 risk assessment
4. Emergency Contact Information: Contact details for emergency situations, particularly relevant for workplace or educational settings
5. Specific Activity Declaration: Additional declarations related to specific activities or events being attended
1. Schedule A - Symptom Checklist: Detailed list of COVID-19 symptoms for reference
2. Schedule B - Privacy Policy: Detailed privacy policy regarding the handling of personal health information
3. Schedule C - Safety Protocols: Current safety protocols and requirements that the declarant must follow
4. Appendix 1 - Contact Tracing Information: Additional information about contact tracing procedures and requirements
5. Appendix 2 - Resource Links: Links to relevant public health resources and guidelines
Authors
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Clauses
Relevant Industries
Healthcare
Education
Manufacturing
Retail
Hospitality
Transportation
Construction
Professional Services
Government
Entertainment
Sports and Recreation
Financial Services
Technology
Non-profit Organizations
Relevant Teams
Human Resources
Health and Safety
Legal
Operations
Facilities Management
Risk Management
Compliance
Administrative Services
Security
Medical Services
Relevant Roles
Human Resources Manager
Health and Safety Coordinator
Facility Manager
Operations Director
Risk Management Officer
Compliance Officer
Medical Officer
Office Manager
Event Coordinator
Security Manager
Legal Counsel
Privacy Officer
Occupational Health Nurse
Department Supervisor
Administrative Assistant
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