COVID19 screening form.
Location of store
*
Martello Alley - 203 B Wellington Street Kingston
Martello on Brock - 66 Brock Street Kingston
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
1. Have you travelled outside of Canada in the last 14 days? (Yes/No)
Yes
No
2. Has someone you are in close contact with tested positive for COVID-19 in the last 14 days?
*
Yes
No
Not Sure
3. Are you in close contact with a person who recently travelled outside of Canada ANDis sick with COVID-19 symptoms?
Yes
No
who is sick with new respiratory symptoms OR
Yes
No
who has symptoms and who is awaiting COVID-19 test results?
Yes
No
4. Do you have a fever? (temperature ≥ 37.8 °C) YES or NO (Screener will have employee take temperature)
Yes
No
Temperature
5. Do you have any of these symptoms
Chills
New or worsening cough (dry or productive)
Barking cough (croup)
Shortness of breath/difficulty breathing
Sore throat
Difficulty swallowing
Loss of taste or smell
Pink eye (conjunctivitis)
Headache that is unusual or long-lasting
Runny or stuffy nose (not related to seasonal allergies or other known causes)
Nausea/vomiting/diarrhea/abdominal pain
Muscle aches
Unexplained fatigue/malaise
Falling more than usual
Other
If you have answered:
NO to all questions – PASS. You may enter the building and proceed as scheduled.
YES to any questions from #1 to #4 – FAIL. Put on a surgical mask, go home immediately and self-isolate. Take the self-assessment at covid-19.ontario.ca, and follow any recommendations given by the tool.
YES to #5 only – FAIL. Go to question #6.
6. Are these symptoms typical for you (i.e. history of allergies, migraines, other known medical condition that usually causes these symptoms)?
YES – Please self-isolate. Contact your doctor for a note confirming that symptoms are typical before returning to work.
NO – Go home immediately and self-isolate. Take the self-assessment at covid-19.ontario.ca, and follow any recommendations given by the tool.
Submit
Should be Empty: