Travel/Contagious Illness Reporting Form

Name:

What site do you work at?

Ajax Pickering

Bowmanville

Oshawa

Port Perry

Whitby

Other, please Specify

Department:

Department worked in last:

Last day worked:

Contact Phone number:

Have you or anyone you are in close contact with travelled outside of Canada in the last 21 days?

Yes

Please provide your symptoms.

Vomiting

Diarrhea

Nausea

Cough

Congestion

Fever

Malaise

Sore Throat

Date of onset of symptoms:

Any family members/household contacts with the same symptoms?

Additional Comments