COVID19 Screening

This form must be completed prior to entering the office at start of each work shift.

    Your Name:

    Your Email:

    1) Do you have any of the following NEW or Worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.

    YESNO Fever or Chills

    YESNO Difficult Breathing or shortness of breath

    YESNO Cough or barking cough

    YESNO Sore throat, trouble swallowing

    YESNO Runny nose/stuffy noise or nasal congestion

    YESNO Decrease or loss of smell or taste

    YESNO Nausea, vomiting, diarrhea, abdominal pain

    YESNO Not feeling well, extreme tiredness, sore muscles ** select no if you received a COVID-19 vaccination in the last 48 hrs

    YESNO Have you traveled outside of Canada in the past 14 days and been told to quarantine (per federal quarantine requirements)

    YESNO Has a doctor, health care provider or public health unit told you that you should currently be isolating (staying at home)?

    Results of Screening Questions

    * If you answer NO to all questions from 1 through 3 you have passed and can enter the workplace.
    * If you answer YES to any question from 1 through 3 you have not passed and should not enter the workplace. You should go home to self-isolate immediately and contact your health care provider or Telehealth Ontario (1-866-797-0000) to get advice or an assessment including if you need a COVID19 test.