COVID-19 EMPLOYEE SCREENING FORM

1. Are you currently experiencing any one of the symptoms below that are new or worsening?
Symptoms should not be chronic or related to other known causes or conditions.
Fever and/or chills

(Temperature of 37.8 degrees celsius/100 degrees fahrenheit or higher)

YesNo
Runny or stuffy/congested nose

(Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have.)

YesNo
Shortness of breath

(Not related to asthma or other known causes or conditions you already have.)

YesNo
Decrease or loss of smell or taste

(Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have.)

YesNo
Cough or barking cough (croup)

(Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have.)

YesNo
Digestive issues like nausea/vomiting, diarrhea, stomach pain

(Not related to irritable bowel syndrome, menstrual cramps or other known causes or conditions you already have.)

YesNo
Sore throat

(Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have.)

YesNo
Difficulty swallowing

(Painful swallowing not related to other known causes or conditions you already have.)

YesNo
Extreme Tiredness

(Unusual fatigue, lack of energy not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have.)

YesNo
Muscle aches

(Unusual, long-lasting muscle aches not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have.)

YesNo
Headache

(Unusal, long-lasting not related to tension-type headache, chronic migraines, or other known causes or conditions you already have.)

YesNo
Pink eye

(Conjunctivitis not related to reoccurring syes or other known causes or conditions you already have.)

YesNo
Falling down often

(For older people.)

YesNo
2. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
YesNo
3. In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?
YesNo
4. In the last 14 days, have you received a COVID alert exposure notification on your cellphone?
YesNo
5. In the last 14 days, have you travelled outside of Canada?
YesNo