Medical Clearance Form (COVID-19 Pandemic)

Employees will require to fill in and submit this form when they have completed all required
quarantine or isolation periods and are cleared to return to work. To ensure the continuing
safety of employees, clients, and the public, no employee placed under quarantine or isolation
may return to work without this form.

Source of Confirmation

Please fill in the appropriate information. You only need confirmation from one of the
following sources.

 Telehealth (Date of call): ______________________

 General practitioner (Date of call or appointment): ______________________

 Walk-in clinic (Date of call or appointment): ______________________

 Health line (date of call): ______________________

Confirmation

I, the undersigned, confirm that I have completed all required quarantine or isolation periods
and am cleared to return to work. I certify that all information in this form is true and correct
to the best of my knowledge. I understand that returning to work without medical clearance
poses a grave risk to the health and wellness of others.

Name: _______________________________

Signature: _______________________________

Date: _______________________________