We require you to fill out the below questionnaire to assist in determining your fitness to work or visitation during the COVID-19 pandemic to provide a safe environment for staff, volunteers, contractors, and families.
The information in this questionnaire is collected and will be used and disclosed solely for the purposes of determining fitness for work or visitation during the COVID-19 pandemic.
Ensure at all times you are following protocols for hand hygiene and also remember to clean your keys, phone, computers and other personal items, as well as work areas.
The questionnaire intends to identify new symptoms or worsening of symptoms that are not related to allergies, chronic or pre-existing conditions.
The self-assessment is only meant as an aid and cannot diagnose you. Anyone who is sick or has any symptoms of illness, including those not listed in this self-assessment tool, should stay home and seek assessment from a health care provider if needed.
Consult a health care provider if you have medical questions.
Those with symptoms normally related to pre-existing conditions or allergies can still go to work or visit.
Your First Name
Your Last Name
Visitor Name (optional, use consumer code for consumers)
Location of Check In
Question 1 of 6
Are you fully vaccinated against COVID-19?
Question 2 of 6
Are you currently experiencing any of these symptoms? Call 911 if you are.
• Severe difficulty breathing(struggling for each breath, can only speak in single words)
• Severe chest pain(constant tightness or crushing sensation)
• Feeling confused or unsure of where you are
• Losing consciousness
Question 3 of 6
Are you:
• Living in a highest risk congregate care setting (for example, long-term care home, retirement home, employer-provided living setting for international Agriculture Workers, hospital school, Education and Community Partnership Program) and/or
• Immunocompromised (for this question, factors such as old age, diabetes and end-stage renal disease are generally not considered immunocompromised)
Examples of being immunocompromised include those:
• Undergoing cancer chemotherapy
• With untreated HIV infection with CD4 T lymphocyte count less than 200
• With combined primary immunodeficiency disorder
• On prednisone medication - more than 20 mg per day (or equivalent) for more than 14 days
• On other immune suppressive medications
Question 4 of 6
Do you have any of these symptoms?
Choose any or all that are new, worsening and not related to other known causes or conditions.
• Fever and/or chills
• Cough
• Shortness of breath
• Decrease or loss of taste or smell
• Muscle aches/joint pain
• Extreme tiredness
• Sore throat
• Runny or stuffy/congested nose
• Headache
• Nausea, vomiting and/or diarrhea
• Abdominal pain
• Pink eye
• Decreased or no appetite (young children only)
Select 'No' if all of these apply:
• Your symptoms have been improving for at least 24 hours (48 hours if you had nausea, vomiting and/or diarrhea) and
• You do not have a fever and
• Only If immunocompromised, you tested negative for COVID-19 on 1 PCR test or rapid molecular test or 2 rapid antigen tests taken 24 to 48 hours apart
Question 5 of 6
Have you been told that you should currently be quarantining, isolating or staying at home?
Could include being told by a doctor, healthcare provider, public health unit, federal border agent, or other government authority.
If yes, follow any guidance or directions that have been provided to you.
Question 6 of 6
In the last 10 days, have you tested positive for COVID-19?
This includes a positive COVID-19 test result on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit.
All questions complete
Please confirm that you have answered the screen questions accurately and submit the form.
