Covid Form

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 or chills YesNo
Cough YesNo
Sore throat, trouble swallowing YesNo
Runny nose/stuffy nose 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 YesNo

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

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

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 questions 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 (1866-797-0000) to find out if they need a COVID-19 test.

Draw your signature in box