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

    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, extremely tiredness, sore muscles

    2)
    YESNO Have you traveled outside of Canada in the past 14 days?

    3)
    YESNO Have you had close contact with a confirmed or probable case of COVID-19?

    Results of Screening Questions

    * If the individual answers NO to all questions from 1 through 3, they have passed and can enter the workplace.
    * If the individual answers YES to any question from 1 through 3, they have not passed and should be advised that they should not enter the workplace (including any outdoor, or partially outdoor, workplaces). They should go home to self-isolate immediately and contact their health care provider or Telehealth Ontario (1-866-797-0000) to find out if they need a COVID-19 test.