Ro-Matt Employee COVID-19 Self Screening Form

COVID-19 Entry Self Assessment

Employee Daily Assessment Form
You must answer “NO” to all the questions in this questionnaire in order to enter Ro-Matt's Office or Plant. If you answer “YES” to any of the questions, please DO NOT come to Ro-Matt or enter the Company’s building.

If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact a health care professional for recommended next steps AND notify your manager. You may also send an email to sick@ro-matt.com.

1. Do you have any of the following NEW or WORSENING symptoms or signs: *

Yes

Fever (37.8 C or 100 F)

Chills

Difficulty breathing or shortness of breath

Cough

Sore throat or trouble swallowing

Runny / stuffy nose or nasal congestion

Decrease or loss of smell or taste

Nausea, vomiting, diarrhea, abdominal pain

Not feeling well, extreme tiredness, sore muscles

2) In the last 14 days have you: *

Yes

Travelled outside of Canada?

Had you had close contact with a confirmed or probable case of COVID-19?

I certify to the best of my knowledge; this information is accurate.
Signature *

Clear
Name *

First Name Last Name
Date *

Year Month Day
Date
Hour Minutes AM/PM Option
Based on your answers, you are requested to not enter the facility as you may pose a risk to others. Please contact your management team by phone ASAP.

Thank you for your co-operation.
Should be Empty:

COVID-19 Entry Self Assessment