N-95 Mask Fit Declaration

N-95 Mask Fit Declaration

Plan A requires all Field Employees to have a current N-95 mask fitting.
Should a Plan A Field Employee be unable to obtain an N-95 mask
fitting due to religious or health reasons, the employee does so at their
own risk and could be denied shifts at any of our contracted Long-
Term Care homes for the duration of any outbreak(s).

x Unable to obtain N-95 Mask Fit

By signing this document, I acknowledge that I am unable
to obtain the N-95 Mask Fit. I understand that I may be
denied access to shifts.

__________________________________________________________
Moniza Pereira Borges
Employee Name (Print)

_______________________________________________________________________
21th August 2020
Employee Signature Date

_______________________________________________________________________
21th August 2020
Witness Date

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N-95 MASK FIT DECLARATION VERSION 1.1. |
February 22, 2019- KL