COVID-19 SCREENING FORM

Type equation here .Dear PepsiCo Employee,

In response to the recent Coronavirus (COVID -19) outbreak and the raised pandemic alert status by the World Health Organisation (WHO),
PepsiCo is taking precautions to lessen the spread of the virus. All new hires who enter a PepsiCo facility or office at this time must be
screened.

Please review the following self screening criteria before visiting our facility:

 Have you travelled or been in contact with anyone who has travelled outside Canada in the past 14 days?

Yes No X

(If yes, HR will follow up and we may ask you to not report to work at this time)

 Have you had close contact with a confirmed positive, presumptive positive, or any possible source of Coronavirus (COVID-19)?
Yes No X

(If yes, PepsiCo asks you to not report to work at this time)

 Have you had a fever of 37.8˚C / 100.4˚F or greater within the past 24 hours? Yes No X

(If yes, PepsiCo asks you to not report to work at this time)

 Do you have any of the symptoms or illnesses listed below?

Cough – New or Worsening Difficulty Breathing/Shortness of Breath

Sore Throat/Painful Swallowing
Headache
Muscle aches/pain including chest
Conjunctivitis (pink eye)
Chills
(If yes, PepsiCo asks you to not report to work at this time)
N N
NRunny Nose/Stuffy Nose (non-allergy related) N
N New loss of taste and smell
N
N Fatigue/Extreme Tiredness
N
Gastrointestinal Symptoms - Nausea/Vomiting/Diarrhea
N N
N

If you do not meet the criteria above, please complete the information below, indicating that you have been provided with this
screening.

Thank you for your cooperation during this unprecedented time .

I HAVE REVIEWED THE ABOVE CRITERIA AND DO NOT HAVE SYMPTOMS AS DESCRIBED.

[Print) Last Name: ______Stonehouse_______________ First Name: ____________Zoey_______________

Signature: Zoey Stonehouse _______

Date: ____________March 19, 2021____________ Contact Number: ____________587-220-8481______________