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. Are you experiencing any of the following NEW or WORSENING symptoms:*

	Yes	No
Fever (37.8 C or 100 F)
Chills
Cough or barking cough (croup)
Difficulty breathing or shortness of breath
Severe Sore throat or trouble swallowing
Decrease or loss of smell or taste
Muscle aches and/or joint pain
Extreme tiredness

2. In the last 10 days, have you been identified as a "close contact" of someone who currently has or is presumed to have COVID-19?*

	Yes	No
If public health has advised you that you do not need to self-isolate, select "No"

3. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?*

	Yes	No
If you already went for a test and received a negative result, select "No"

4. Have you been in close physical contact with someone who either:*

	Yes	No
Is sick with a new cough, fever, difficulty breathing, or symptoms associated with COVID-19 in the last 10 days?
Returned from outside of Canada in the last 14 days

5. In the last fourteen (14) days have you travelled outside of Canada?*

	Yes	No
If you are exempt from federal quarantine requirements (i.e. if you are fully vaccinated and have met specific conditions), select "No".

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

Clear
Name*

First NameLast Name
Date*

YearMonthDay
Date
Hour MinutesAM/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.
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COVID-19 Entry Self Assessment