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.
Those with symptoms normally related to pre-existing conditions or allergies can still go to work or visit.
Your First Name
Your Last Name
Location of Check In
Question 1 of 6
Are you fully vaccinated against COVID-19?
If you are immunocompromised, select 'No'
Question 2 of 6
Are you currently experiencing any of these symptoms?
• Fever and/or chills
• Cough or barking cough (croup)
• 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
Select 'No' if you have already completed your isolation period of 5 days, and:
• You don't have a fever, and
• Your symptoms have been improving over 24 hours (48 if you have nausea, vomiting and/or diarrhea)
Question 3 of 6
In the last 14 days, have you travelled outside of Canada and been told to quarantine (per the federal quarantine requirements)?
Question 4 of 6
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
Question 5 of 6
In the last 5 days, have you tested positive for COVID-19? (confirmed on a lab-based PCR test, rapid molecular test, rapid antigen test, or home-based self testing kit)
Question 6 of 6
Do any of the following apply?
• You live with someone who is currently isolating because of a positive COVID-19 test
• You live with someone who is currently isolating because of COVID-19 symptoms
• You live with someone who is isolating while waiting for COVID-19 test results
Select 'No' if:
• You are 18 or older and have received your booster, and/or
• You are 17 or younger and are fully vaccinated, and/or
• You completed your isolation after testing positive in the last 90 days (using a rapid antigen, rapid molecular, or PCR test), and/or
• You household member is isolating because of COVID-19 symptoms but has already tested negative on one PCR or rapid molecular test, or two rapid antigen tests
All questions complete
Please confirm that you have answered the screen questions accurately and submit the form.
You may proceed to work or with your scheduled visit.
This result is no longer valid if your situation changes during the day (for example, you start experiencing symptoms).
If you feel sick or not well, even with symptoms not listed in this screening tool, please stay home. Talk to a health care provider if necessary.
You have answered "Yes" to one or more of the questions and are not permitted to attend work or visit at this time and you must stay home using sick credits
You should isolate (stay home) for 5 days from when symptoms started and stay isolated until you have no fever and your symptoms have been improving for at least 24 hours (48 hours for nausea, vomiting, and/or diarrhea), whichever is longest. Please talk with a doctor/health care provider, visit a clinical assessment centre or call Telehealth Ontario (1-866-797-0000) to get advice or an assessment, including if you need a COVID-19 test, if eligible.
