Employee COVID-19 Self Screen

Name

Phone Number - Clients and Visitors only

Area CodePhone Number

Division/Agency

Date

Initials

1. Do you have any of the following symptoms: fever/feverish, new or worsening cough, or shortness of breath?

YesNo

2. Are you experiencing any of the following additional symptoms other than what is usual or allergies:

3. Have you traveled outside of Canada within the last 14 days?

YesNo

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

YesNoOther

If you have answered YES to any of the above questions, please DO NOT enter the building. Contact your manager for further instruction.

NOTE: If employees begin to experience symptoms while at work, they MUST notify their Manager immediately.

________________________________________________________

Please only fill out this section if you have identified symptoms and have been instructed by your manager/corporate services to remain home and self isolate

I have had a COVID Test?

YesNo

If Yes, date you were tested

If No, expected date to be tested

My self-isolation start date is:

At this time, my expected self-isolation end date is:

Daily COVID-19 Self Screen Questionnaire