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Customer COVID-19 – Declaration Form

  • The COVID-19 virus is problematic as many people experience symptoms so mild that they do not seek medical attention and therefore spread the virus to others without realizing it. This tool has been created to minimize this risk for Orangeville Hydro staff.

    Please instruct Customer to complete the following declaration before entering the property of Orangeville Hydro. This form must be completed 24 hours prior to entering the office of Orangeville Hydro.

  • Have you or someone in your household had a fever, new cough, or difficulty breathing, muscle aches, fatigue, headache, sore throat (or a combination of these symptoms)? * Required

    If yes, is answered entry into the office is not permitted by Orangeville Hydro Staff.

    If no is answered, please answer the following questions:

  • Has anyone in the household received public health or medical advice to self-monitor or self-isolate?
  • Have you or anyone in your household travelled outside Canada in the past 14 days?
  • Have you or anyone in your household been in close contact with someone who has been tested or tested positive for COVID-19?
  • Have you or anyone in your household been in close contact with a person with acute respiratory illness who has travelled outside Canada in the last 14 days?
  • If answered no to all of these questions the Customer is permitted to enter the office of Orangeville Hydro.

    If answered yes to any of these questions the Customer is not to be permitted to enter the office of Orangeville Hydro.

    Completion of this declaration is voluntary. However, if not completed Orangeville Hydro staff will not allow a Customer to enter the office of Orangeville Hydro. Please complete details below to confirm you have read and understand this declaration.

  • Name * Required