Coronavirus Screening Form Employees

COVID19 Screening Form Employees
Full Name *

First Name Last Name
DateTime
Where are you working from? *

Home Office Client Site
Are you currently experiencing any of these? Call 911 if you are *

Severe difficulty breathing (Struggling for each breath, can only speak in single words) Severe chest pain (constant tightness or crushing sensation) Feeling confused or unsure of where you are Losing consciousness None of the above
Do you have any of the following symptoms not related to other known causes or condition? *

Fever (hot to touch, temp of 37.8C or higher) Chills Cough that's new/worsening (continuous, more than usual) Barking cough,making a whistling noise when breathing Shortness of breath (out of breath, unable to breath deeply) Sore throat Difficulty swallowing Runny nose(unrelated to allergies or other known causes or conditions) Stuffy or congested nose (unrelated to allergies or other known causes or conditions) Lost sense of taste or smell Pink eye (conjunctivitis) Headache that's unusual or long lasting Digestive issues like nausea/vomiting, diarrhea, stomach pain (not related to other known causes or condition) Muscle aches that is unusual (fatigue, lack of energy) Falling down often None of the above
Have you been in contact with anyone in the last 14 days who is experiencing these symptoms? *

Yes No
Have you been in contact with anyone who has since tested positive for COVID-19? *

Yes No
Have you been in a group of more than 10 recently? *

Yes No
Have you traveled outside Ontario in the last 14 days? *

Yes No
Notes / Comments
Disclaimer: By typing my name below. I am electronically signing this application.
Signature *
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COVID19 Screening Form Employees