H1N1 Preparedness Assessment Forms
You'll be surprised how little time and effort this takes!
Select the form(s) that are appropriate to your workplace.
You may find that some of your workers fall under one category, while others fall under another. In this case, two forms are required to address the differences.
Take a look at this completed sample form to see what a completed one might look like.
Low Risk Services form
For workers whose daily duties seldom require them to be in direct contact (within 2 metres) with the public, such as office workers, clerks, accountants, school teachers, etc.
Low-Moderate Risk Services form
For workers whose duties require them to be in regular contact (within 2 metres) with the public, such as cashiers, tellers, salers persons, food servers , etc.
Also for workers that regularly come in contact with a potentially contaminated environment (e.g., cleaning equipment or areas visited by the public).
Moderate-High Risk Services form
For workers who have direct face to face contact (within 2 metres) with persons with confirmed or probable H1N1 while providing personal care or supervision (e.g., personal caregivers, inter-facility transport of the ill, cleaning a room inhabited by H1N1 patient).
Yukon Workers' Compensation Health and Safety Board
