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Screening Form
(Covid-19)

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.