COVID-19 EMPLOYEE SCREENING 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
Runny/stuffy nose or nasal congestion
YesNo
Difficulty breathing or shortness of breath
YesNo
Decrease or loss of smell or taste
YesNo
Cough
YesNo
Nausea, vomiting, diarrhea, abdominal pain
YesNo
Sore throat, trouble swallowing
YesNo
Not feeling well, extreme tiredness, sore muscles
YesNo
2. Have you travelled outside of Canada in the past 14 days?
YesNo
3. In the last 14 days, have you been in close physical contact with a person who either: Is currently sick with a new cough, fever, or difficulty breathing; OR Returned from outside of Canada in the last 2 weeks?
YesNo