CBCISAFETY-2022-_____

SAFETY CLEARANCE FORM

(Reporting on-site)

This is to certify that MR/MS.:________________________________________________

Has no manifestation of any signs and symptoms attributed to COVID-19 infection and has
completed the isolation/quarantine period of ____________ days as advised by the attending
physician/recommended by the Bayad Safety Officer.

This certification is issued upon request of the above-named person for the purposes of
clearance to report back to work.

Issued on: ____________________ (Date)

Approved by:

_______________________
Department Head

Noted by:

__________________
Safety Officer