Employee Screening Form

Name *

First Name

Last Name

Fever or chills *

Yes

No

Cough or shortness of breath *

Yes

No

Decrease or loss of smell/taste *

Yes

No

Sore throat/difficulty swallowing *

Yes

No

Pink Eye *

Yes

No

Runny, stuffy or congested nose *

Yes

No

Unusual/long-lasting headache *

Yes

No

Extreme fatigue, muscle aches or falling down often *

Yes

No

Digestive issues, diarrhea or stomach pain *

Yes

No

Have you travelled outside of Canada in the past 14 days *

Yes

No

In the last 14 days, has a public health unit identified you as a close contact of someone who currently has COVID-19? *

Yes

No

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?box 11 *

Yes

No

In the last 14 days, have you received a COVID Alert exposure notification on your cell? If you already went for a test and got a negative result, select “No.” *

Yes

No