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COVID-19 Symptom Reporting Form - Glenwood

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?

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.