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
Other
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
Take a Picture of your Antigen Test Result
Upload Antigen Test Result
Browse Files
Cancel
of
Antigen Test Result
*
Positive
Negative
N/A - Tested + in the Last 90 Days
Notes / Comments
Disclaimer: By typing my name below. I am electronically signing this application.
Signature
*
Submit
Should be Empty: