COVID-19 Protocol – Customer Consent Form

EfficiencyOne COVID-19 Customer Consent Form


As a result of the worldwide outbreak of the COVID-19 Pandemic, EfficiencyOne, operating as the Efficiency Nova Scotia franchise, has implemented an extensive protocol to reduce the risk of spread of COVID-19 while providing its Programs, (the “COVID-19 Protocol”). EfficiencyOne is now requiring its Service Providers who deliver its Programs to comply with the COVID-19 Protocol. A summary of the COVID-19 Protocol is set out in Schedule “A” attached below.

Although EfficiencyOne has implemented the COVID-19 Protocol, there is still a risk that you and those in your premises may be exposed to COVID-19 by allowing an EfficiencyOne Service Provider into your premises. Therefore, EfficiencyOne requires you to carefully consider and review such risks as well as this Consent Form. In the event you wish to allow an EfficiencyOne Service Provider into your premises as part of your participation in an EfficiencyOne Program, then EfficiencyOne will require you to first sign this Consent Form.

I, ___________________________________(customer name), of _________________________________________________________(address), am a participant in the________________________________________________________ (insert name of EfficiencyOne/ENS program, and I acknowledge and confirm all the following:

  • I am aware of the highly contagious nature of COVID-19;
  • I have read this Consent Form and the attached Schedule “A”, and I understand the main requirements that Service Providers must follow as a result of EfficiencyOne’s COVID-19 Protocol;
  • I understand and acknowledge that allowing an EfficiencyOne Service Provider(s) into my premises as part of my participation in the above-noted EfficiencyOne Program, increases the risk of exposing myself and all those in my premises to COVID-19 and as a result, myself and all those in my premises may become ill with COVID-19 and suffer any complications associated with COVID-19, including but not limited to death. I accept this risk and consent to an EfficiencyOne Service Provider(s) entering my premises for the purpose of participating in the above-noted Program;
  • I will comply with all requests of EfficiencyOne and its Service Providers in order to reduce the risk of spread of COVID-19 in my participation in the above-noted Program; and
  • I understand that EfficiencyOne and/or its Service Providers are relying upon my answers to their COVID-19 screening questionnaire for the safety of their employees. I will immediately advise EfficiencyOne if any information I have provided in the COVID-19 screening questionnaire changes in the 14 day period after the Service Provider has been in my premises, or prior to any return visit by the Service Provider in the future

 

By signing below, I confirm that I have had the opportunity to review and ask any questions I have about EfficiencyOne’s COVID-19 Protocol, and I understand and agree to the terms set out above.

______________________________       _________________________________

Participant Signature                                                                Date

(If the Participant is a Corporation,

I have authority to bind the Corporation)

 


Schedule “A”

Summary of EfficiencyOne COVID-19 Protocol for Service Providers

 

Efficiency One requires its Service Providers to take steps to protect our Clients and Customers from COVID-19 when they are providing services at your home or business. Our Service Providers, their employees and any subcontractors delivering services on our behalf are required to do the following:

  • Comply with Orders and Directives of the Chief Medical Officer of Public Health for the Province of Nova Scotia, including compliance with physical distancing and gathering limit requirements.

 

  • Maintain records and daily logs of employee site visits and individual contacts in the event contact tracing for Public Health purposes is required.

 

  • Conduct pre-entry risk assessments. If risks to either employees or occupants relating to COVID-19 are identified, follow protocol to either (1) reschedule site visits or (2) take steps to mitigate risks.

 

  • Ensure all employees attending sites are trained in COVID-19 Safe Work Practices and procedures for the proper use of Personal Protective Equipment, including face masks and coverings and single-use gloves

 

  • Ensure all employees attending sites have been screened to confirm they are not, or are not a close contact of, a person who or is:
    • Travelled out of the Province within the past 14 days;
    • Been diagnosed with COVID-19 and has not recovered;
    • Awaiting results of COVID-19 testing;
    • Exhibiting symptoms consistent with the presentation of COVID-19;
    • Required or has otherwise been directed to self-quarantine

Employees falling within the above categories are not permitted to attend a Site.

  • Ensure all employees have access to supplies for the purpose of maintaining hand hygiene, including hand sanitizer and sanitizing wipes and/or spray.

 

  • Ensure all employees have access to supplies for the purpose of following workplace cleaning practices and protocols to clean and disinfect work areas (including vehicles), high touch surfaces and equipment before and after use.

 

  • Ensure all employees wear non-medical masks and face coverings and single-use gloves while on site.

 

  • Ensure employees do not eat on site.

For a complete list and detail regarding our Service Providers’ obligations, please visit https://www.efficiencyns.ca/efficiencyone-service-provider-obligations/