Covid-19 Screening

COVID-19 Screening Form

Full Name

Your Email

Date

Your Phone

Required Screening Questions

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?

Yes

Difficulty breathing or shortness of breath?

Yes

Cough?

Yes

Sore throat, trouble swallowing?

Yes

Runny nose / stuffy nose or nasal congestion?

Yes

Decrease or loss of smell or taste?

Yes

Nausea, vomiting, diarrhea, abdominal pain?

Yes

Not feeling well, extreme tiredness, sore muscles?

Yes

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

Yes

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

Yes

Results of Screening Questions

If you have answered NO to all questions from 1 through 3, you have passed and can enter the workplace.

If you have answered YES to any questions from 1 through 3, you have not passed and you are advised not to enter the workplace (including any outdoor, or partially outdoor, workplaces). You should go home or self-isolate immediately and contact your healthcare provider or Telehealth Ontario (1 866-797-0000) to find out if you need a COVID-19 test.