COVID-19 Questionnaire

All staff members must complete a screening questionnaire before they enter the building. Completed screening questionnaires will be stored securely in our office.

( * = Required field)

Name*
Are you currently experiencing one or more of the symptoms below that are new or worsening? (Symptoms should not be chronic or related to other known causes or conditions.)
- Fever and/or chills
- Cough or barking cough (croup)
- Shortness of breath
- Decrease or loss of smell or taste
- Fatigue, lethargy, malaise and/or muscle aches/joint pain
- Nausea, vomiting and/or diarrhea
Are you currently experiencing one or more of the symptoms below that are new or worsening? (Symptoms should not be chronic or related to other known causes or conditions.): Fever and/or chills, Cough or barking cough (croup), Shortness of breath, Decrease or loss of smell or taste, Fatigue, lethargy, malaise and/or muscle aches/joint pain, Nausea, vomiting and/or diarrhea*
Yes No
In the last 14 days, have you travelled outside of Canada and been advised to quarantine (as per the federal quarantine requirements)?*
Yes No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?*
Yes No
In the last 10 days, have you tested positive on a rapid antigen test or a homebased self-testing kit?*
Yes No
In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?*
Yes No
In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?*
Yes No
Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?*
Yes No
Comments
This field is for validation purposes and should be left unchanged.

If you answer NO to all questions, you can enter the workplace.

If you answer YES to any questions, you should not enter the workplace. You should go home to self-isolate immediately and contact your health care provider or Telehealth Ontario (1-866-797-0000) to find out if you need a COVID-19 test.