SITE SIGN-IN AND PJHA All individuals must complete this form each time they arrive on a Blackrock site. If you require a site safety orientation please call 587-803-1412 prior to entering the premises. The site muster point is always at the back of the Blackrock sign Job Number or Site Address Name * First Name Last Name Company/Organization Phone Number Are you experiencing any of the following: * Severe difficulty breathing (e.g., struggling for each breath, Speaking in single words) Severe chest pain Having a very hard time waking up Feeling confused Lost consciousness None of the above Are you experiencing any of the following: * Shortness of breath at rest Inability to lie down because of difficulty breathing Chronic health conditions that you are having difficulty managing because of your current respiratory illness None of the above In the past 14 days, were you notified that you were connected to an outbreak by: * AHS Your employer The organizer of a social or sporting event you attended None of the above In the past 10 days, have you experienced any of the following: * Fever New onset of cough or worsening of chronic cough New or worsening shortness of breath New or worsening difficulty breathing Sore throat Runny nose None of the above Do you have any of the following: * Chills Painful swallowing Stuffy nose Headache Muscle or joint ache Feeling unwell, fatigue or severe exhaustion Nausea, vomiting, diarrhea or unexplained loss of appetite Loss of sense of smell or taste Conjunctivitis (pink eye) None of the above In the past 14 days, were you notified that you are a close contact of a confirmed case of COVID-19 by: * AHS Your employer Someone who tested positive for COVID-19 None of the above In the past 14 days, did you return from travel outside of Canada? * Yes No - Do not touch your eyes, nose or mouth. - Cough or sneeze into your sleeve, not on your hands. - Avoid close contact with people and keep 2m apart. - Check house before entering. Max. 1 trade cohort interior and one exterior - Disinfect as you go and avoid touching surfaces not related to your work. - Use your own tools. If you share, sanitize prior to and after each use. - Sanitize machines before each use (door handles, steering wheels and controls). PJHA - A Pre-Job Hazard assessment must be completed for each time your scope of work changes Is your WCB account active and current? * Yes No (You are not cleared to commence work until arrangements for coverage are made with Blackrock in writing) Do you require a Blackrock representative to provide you with a site and safety orientation? * Yes (You are not cleared to proceed with work until this has been completed) No Scope of work to be preformed * Risk of Harm? * Imminent danger Serious Minor Not Applicable Do you and your team have the tools, PPE and knowledge to proceed with the above scope of work safely * Yes No (You are not cleared to proceed with work until you can do so safely) List the sequence of job steps, hazards and required actions or procedures for any tasks in your scope you or your team members are not familar or comfortable preforming List the PPE you will be utilizing for your scope of work We have reviewed the hazards relating to this scope of work and agree to take the action required to remove hazards, reduce risk, and work safely. * Yes No (Please make arrangements with Jeff at 587-803-1412) Please list the names of all of your onsite team that completed this form with the person responsible for your teams safety being listed first. SUBMITTEDIf you answered anything but “None of the Above” to any of the questions and “No” to the travel question in the Covid 19 Questionnaire, please do not enter the site and make arrangements with our site supervisor at 587-803-1412. Thank you and stay safe
