Covid 19 Screening

* Indicates required field

NAME *

First

Last

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.

FEVER AND/OR CHILLS *

Yes No

Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher.

COUGH OR BARKING COUGH (CROUP) *

Yes No

Continuous, more than usual, making a whistling noise when breathing, not related to other known causes or conditions (for example, asthma, post-infectious reactive airways, COPD)

DIFFICULTY BREATHING OR SHORTNESS OF BREATH *

Yes No

Out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma)

DECREASE OR LOSS OF SMELL OR TASTE *

Yes No

Not related to other known causes or conditions (for example, allergies, neurological disorders)

DIFFICULTY SWALLOWING *

Yes No

Painful swallowing, not related to other known causes or conditions

SORE THROAT *

Yes No

Not related to other known causes or conditions (for example, seasonal allergies, acid reflux)

PINK EYE *

Yes No

Conjunctivitis, not related to other known causes or conditions (for example, reoccurring styes)

RUNNY NOSE/STUFFY NOSE OR NASAL CONGESTION *

Yes No

Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather)

HEADACHE (UNUSUAL OR LONG LASTING) *

Yes No

Not related to other known causes or conditions (for example, tension-type headaches, chronic migraines)

NAUSEA, VOMITING, DIARRHEA, ABDOMINAL PAIN *

Yes No

Not related to other known causes or conditions (for example, irritable bowel syndrome, menstrual cramps)

MUSCLE ACHES THAT ARE UNUSUAL OR LONG LASTING *

Yes No

Not related to other known causes or conditions (for example, a sudden injury, fibromyalgia)

EXTREME TIREDNESS THAT IS UNUSUAL *

Yes No

Fatigue, lack of energy, not related to other known causes or conditions (for example, depression, insomnia, thyroid dysfunction)

2. Have you travelled outside of Canada in the past 14 Days?

Have you travelled outside of Canada in the past 14 Days? *

Yes No

3. In the last 14 days, has a public health unit identified you as a close contact of someone who currently has COVID-19?

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

Yes No

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

Has a doctor, health care provider, or public health unit told you that you should currently be isolating? *

Yes No

5. In the last 14 days, have you received a COVID Alert exposure notification on your cell? If you already went for a test and got a negative result, select “No.”

In the last 14 days, have you received a COVID Alert exposure notification on your cell? *

Yes No

Submit

RESULTS OF SCREENING QUESTIONS:

If you have answered NO to ALL QUESTIONS FROM 1 THROUGH 5, you have passed and can enter the workplace.
If you have answered YES to ANY QUESTIONS FROM 1 THROUGH 5, you have not passed and are required to leave workplace immediately (including any outdoor, or partially outdoor, workplaces). Please go home to self-isolate immediately and contact their health care provider or Telehealth Ontario (1 866-797-0000) to find out if you need a COVID-19 test.
Please contact us with your return to work and/or your financial options (ie. sick time, vacation, unpaid leave of absence or record of employment)

RequiredCOVID-19 Screening Questions(for employees & essential visitors)

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.

2. Have you travelled outside of Canada in the past 14 Days?

3. In the last 14 days, has a public health unit identified you as a close contact of someone who currently has COVID-19?

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

​5. In the last 14 days, have you received a COVID Alert exposure notification on your cell? If you already went for a test and got a negative result, select “No.”

Required
COVID-19 Screening Questions
(for employees & essential visitors)

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

5. In the last 14 days, have you received a COVID Alert exposure notification on your cell? If you already went for a test and got a negative result, select “No.”