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)

  • YesNo
    Fever or chills
    Difficulty breathing or shortness of breath
    Sore throat, trouble swallowing
    Runny nose/stuffy nose or nasal congestion
    Decrease or loss of smell/taste
    Nausea, vomiting, diarrhea, abdominal pain
    Not feeling well, extreme tiredness, sore muscles
    Pink eye
    Muscle aches
    Extreme tiredness
    Falling down often
  • YesNo
  • YesNo
  • YesNo
  • YesNo
  • YesNo
  • 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.

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