Employee COVID Screening Questionnaire

DATE:

  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.
    • 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 or stuffy/congested nose: Not related to seasonal allergies, being outside in the cold weather, or other known causes or conditions you already have.
    • i) Headache: Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have).
      If you have received a COVID 19 vaccination in the last 48 hours and are experiencing a mild headache that only began after vaccination select “NO”.
    • j) 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.
    • k) Muscle aches: Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have).
      If you have received a COVID 19 vaccination in the last 48 hours and are experiencing mild muscle aches that only began after vaccination select “NO”.
    • l) Fatigue: Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have).
    • m) Falling down often: For older people.

Results of Screening Questions:

  • If you answered NO to all questions from 1 through 7, you can enter the workplace.

    In the workplace, the worker must continue to follow all public health and workplace control measures, including masking, maintaining physical distance and hand hygiene.

    In addition to following all the workplace’s regular control measures, if the worker has received a COVID-19 vaccination in the last 48 hours and has mild headache, fatigue, muscle ache and/or joint pain that only began after immunization, and no other symptoms, the worker must wear a surgical/procedure mask for their entire shift at work even if not otherwise required to do so. Their mask may only be removed to consume food or drink and must remain at least two meters away from others when their mask has been removed. If the symptoms worsen, continue past 48 hours, or if they develop other symptoms, they should leave work immediately to self-isolate and seek COVID-19 testing.

  • If you answered YES to any questions from 1 through 7, you must 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 the worker answered YES to question 7, they must be advised to stay home (go home), along with the rest of the household, until the sick individual gets a negative COVID-19 test result, is cleared by their local public health unit, or is diagnosed with another illness.
  • If any of the answers/information to these screening questions change during the day, you should inform your Human Resources or your Manager of the change immediately and go home to self-isolate immediately and 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 7 questions?

    Click SUBMIT after selecting your option below:

    NOTES:

  • 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.
  • REF Question 6: Effective July 5, 2021, fully vaccinated Canadians may be exempt from post-travel COVID-19 quarantine restrictions. For those workers who are not fully vaccinated AND either 1) live with an individual who has recently traveled outside of Canada OR 2) live with an individual who is self-isolating due to a high-risk exposure: These workers are permitted to attend work, but they are required to stay home except for essential reasons for the duration of the contact’s isolation period. Essential reasons include: attending school/childcare/work and essential errands such as, obtaining groceries, attending medical appointments or picking up prescriptions.
  • Version 5- July 7, 2021