Daily Fit for Work or Essential Visitor Screening Questionnaire
Check in Location 61 King
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 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
Question 1 of 6
Do you have any of the following symptoms which are new: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose?, or any worsened symptoms listed prior that is not a regular experienced symptom associated with diagnosed allergies, chronic or pre-existing conditions?
Question 2 of 6
Have you returned to Canada from outside the country (including USA) in the past 14 days?
Question 3 of 6
In the past 14 days, at work or elsewhere, while not wearing appropriate personal protective equipment, did you have close contact* with someone who has a probable** or confirmed case of COVID19?
*Close contact includes providing care, living with or otherwise having close prolonged contact (within 2 meters) while the person was ill, or contact with infectious bodily fluids (e.g. from a cough or sneeze) while not wearing recommended personal protective equipment.
**Probable case is a person with clinical illness who had close contact to a lab-confirmed COVID-19 case, while not wearing appropriate personal protective equipment, OR a person with clinical illness who meets the COVID-19 exposure criteria. Clinical illness of a probable case is new onset/exacerbation of following symptoms: fever (over 38 degrees Celsius), cough, shortness of breath (SOB)/difficulty breathing, sore throat or runny nose. Exposure criteria for a probable case is a person who, in the 14 days before onset of illness: had any history of travel outside of Canada; OR had close contact with a confirmed or probable case of COVID-19; OR is a close contact of a traveler with acute respiratory illness who returned from outside Canada in the previous 14 days; OR had direct exposure to biological material known to contain Covid-19
Question 4 of 6
In the past 14 days, at work or elsewhere, while not wearing appropriate personal protective equipment, did you have close contact* with a person who had acute respiratory illness that started within 14 days of their close contact* to someone with a probable** or confirmed case of COVID-19?
*Close contact includes providing care, living with or otherwise having close prolonged contact (within 2 meters) while the person was ill, or contact with infectious bodily fluids (e.g. from a cough or sneeze) while not wearing recommended personal protective equipment.
**Probable case is a person with clinical illness who had close contact to a lab-confirmed COVID-19 case, while not wearing appropriate personal protective equipment, OR a person with clinical illness who meets the COVID-19 exposure criteria. Clinical illness of a probable case is new onset/exacerbation of following symptoms: fever (over 38 degrees Celsius), cough, shortness of breath (SOB)/difficulty breathing, sore throat or runny nose. Exposure criteria for a probable case is a person who, in the 14 days before onset of illness: had any history of travel outside of Canada; OR had close contact with a confirmed or probable case of COVID-19; OR is a close contact of a traveler with acute respiratory illness who returned from outside Canada in the previous 14 days; OR had direct exposure to biological material known to contain Covid-19
Question 5 of 6
In the past 14 days, at work or elsewhere, while not wearing appropriate personal protective equipment, did you have close contact* with a person who had acute respiratory illness who returned from travel outside of Canada in the 14 days before they became sick?
*Close contact includes providing care, living with or otherwise having close prolonged contact (within 2 meters) while the person was ill, or contact with infectious bodily fluids (e.g. from a cough or sneeze) while not wearing recommended personal protective equipment.
Question 6 of 6
Did you have a direct exposure to biological material (i.e. primary clinical specimens, virus culture isolates, droplets, client spray equipment) known to possibly contain COVID-19?
You have completed all of the quesitons.
Please confirm that you have answered the screen questions accurately.
Thank you for completing the screening.
You have answered "YES" to one of the screening questions, you are not permitted to attend work or visit at this time and you must stay home using sick credits. Please call Health Unit for further instructions or visit the local COVID-19 testing centre. Inform your Manager of this, and a clearance date from the Health Unit of when you can return to work.
Thank you for completing the screening.
You can proceed to enter the building to complete a body temperature check at the designated screening table. If you leave the building and return or develop symptoms in the same day, please complete a new questionnaire and temperature check.
