SIEMENS SELF-DECLARATION QUESTIONNAIRE ‘The health, safety and well-being of our employees at Siemens is the highest priority. As a result of the COVID-19 pandemic, we are applying precautionary screening processes, physical distancing, respiratory and hygiene measures to safeguard employees. We ask for your understanding and cooperation in answering the following questions prior to entering the site: This questionnaire is to be used for Latearing an employee who was required to selfisolate for 14 days and has NOT TESTED POSITIVE for COVID-19 [as afit for duty confirmation where required by Siemens local management. Linew employees Ifany of below questions (1-5) are YES, please do not enter the facility and notify your Manager, EHS and/or HR contact. # | Yes | No Question 1/0 |O In the last 14 days, have you or any member of your household travelled outside of Canada, and been advised to quarantine as per the federal quarantine requirements? If you are fully vaccinated* and have not been advised to quarantine, select "No". In the last 10 days, have you or any member of your household: (a) been in close contact** with any confirmed or probable*** case of COVID-19; (b) been identified by a public health unit as a close contact** with a confirmed or probable*** case of COVID-19; or {c) received a COVID Alert exposure notification? If you are fully vaccinated* and have not been advised to self-isolate by public health, select “No”. Has a doctor, health care provider, or public health unit told you or any member of your household to isolate, or are you waiting for the test results for COVID-19? In the last 10 days, have you tested positive on a rapid antigen test or a home-based self testing Ki? Ifyou have since tested negative on a lab-based PCR test, select “No”. In the last 48 hours, are you or any member of your household experiencing any of the following new or worsening symptoms: ‘Symptoms should not be chronic or related to other known causes or conditions. ‘© fever and/or chills, ‘difficulty breathing or shortness of breath, ‘© cough or barking cough, ‘+ decrease or loss of smell or taste, ‘© unusual fatigue, extreme tiredness, muscle aches/joint pain (not related to getting a COVID-19 vaccine in the last 48 hours) ‘+ headache that is unusual or long lasting, If you are fully vaccinated* and have contacted public health which advised you it is not necessary to self-isolate, select “No”. Do you agree to: (i) respect social distancing (2 metres) at all times and any other site-specific rules communicated to you; AND (ii) where the minimum distance of 2 metres rule cannot be permanently complied with as per risk assessment, you agree that PPE shall be worn as required? 36-01-0248 2021-10-13 Rev.08 Page 1 of 2SIEMENS By signing this form, you declare that: (i) you have read and understood this information and have completed this document honestly and to the best of your knowledge; and (ii) you consent to Siemens’ collection, use and storage of your personal information for the purpose of safeguarding its employees health, Please note this form will be held securely and destroyed no later than 30 days after it has been completed by you. IF ANY OF THESE ANSWERS CHANGE WHILE YOU ARE WORKING FOR SIEMENS, PLEASE NOTIFY YOUR MANAGER, EHS OR HR CONTACT IMMEDIATELY. ‘Fully vaccinated is defined as an individual 214 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series. ** Close Contact means a person who was within 6 ft/2 m of another person diagnosed with COVID-19 for a cumulative total of 15 minutes or more aver a 24 hours period. Probable Case: 1) Aperson (who has not had a laboratory test) with symptoms compatible with COVID-19 AND who: a. Travelled to an affected area (including inside of Canada) in the 14 days prior to symptom onset; oR Had close contact** with a confirmed case of COVID-19; OR Lived or worked in a facility known to be experiencing an outbreak of COVID-10 (e.g,, long-term, case, prison, etc.) oR 2) person with symptoms compatible with COVID-19 in whom laboratory diagnosis of COVID-19 is inconclusive. Employee Name: Print/Signature Date Manager/Supervisor | Print/Signature Date Approval 36-01-0248 2021-10-13 Rev.08 Page 2of2