Construction COVID-19 Return-to-Work Clearance Form
Employee Information
Full Name
Employee ID
Position/Title
Construction Site/Location
Contact Number
Medical Information
Last Day Worked
Intended Return Date
Date of COVID-19 Diagnosis (if applicable)
Date Symptoms Resolved
COVID-19 Health Clearance
No fever for at least 24 hours without the use of fever-reducing medication
Symptoms have improved
Isolation requirements completed as per health authority guidance
Received clearance from healthcare provider
Additional Notes (optional)
Employee Signature
Date
Health/Safety Representative Signature
Date