Employee COVID Screening Questionnaire

DATE:

  1. Are you currently experiencing any one of the following NEW or WORSENING symptoms or signs?
    Symptoms should not be chronic or related to other known causes or conditions.
    • a) Fever or chills: Temperature of 37.8 degrees Celcius/100 Fahrenheit or higher.
    • b) Cough or barking cough (croup): Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions.
    • c) Shortness of breath: Not related to asthma or other known causes or conditions you already have.
    • d) Sore throat: Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have.
    • e) Difficulty swallowing: Painful swallowing not related to other known causes or conditions you already have.
    • f) Decrease or loss of Smell or Taste: Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have.
    • g) Pink eye: Conjunctivitis not related to reoccurring styes or other known causes or conditions you already have.
    • h) Runny/stuffy nose or nasal congestion: Not related to seasonal allergies, being outside in the cold weather, or other known causes or conditions you already have.
    • i) 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.
    • j) Muscle aches: Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have).
    • k) Extreme tiredness: Unusual fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have).
    • l) Headache: Unusual, long-lasting not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have.
    • m) Falling down often: Not related to a slip and fall or uneven surfaces, icy surfaces.

Results of Screening Questions:

  • If you answered NO to all questions from 1 through 6, you can enter the workplace.
  • If you answered YES to any questions from 1 through 6, you should not enter the workplace, (including any outdoor, or partially outdoor spaces) please stay home (go home) to self-isolate contact Human Resources or your manager (519-737-7535) to report your situation. Immediately call your health care provider or Telehealth Ontario (1-866-797-0000) to get advice or an assessment including if you require a COVID-19 test.
  • If any of the answers to these screening questions change during the day, you should inform your manager/human resources of the change immediately and go home to self-isolate. Once home contact your health care provider or Telehealth Ontario (1-866-797-0000) to get advice or an assessment including if you require a COVID-19 test.
  • Did you answer YES to ANY of the above 6 questions?

    Click SUBMIT after selecting your option below:

    NOTE: All records are kept for a minimum of 30 days in accordance with the Chief Medial Officer of Health’s requirements. Any record created as part of the worker screening will only be disclosed as required by law.
    Version 4- February 26, 2021