Scarsview COVID Screening for Customers
Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.


Sign in to Google to save your progress. Learn more
Email *
Fever or Chills *
Required
Difficulty breathing or shortness of breath *
Required
Cough *
Required
Sore throat, trouble swallowing *
Required
Runny nose/stuffy nose or nasal congestion *
Required
Decrease or loss of smell or taste *
Required
Nausea, vomiting, diarrhea, abdominal pain *
Required
Not feeling well, extreme tiredness, sore muscles *
Required
Have you traveled outside of Canada in the past 14 days? *
Required
Have you had close contact with a confirmed or probable case of COVID-19 *
Required
Your Name *
Contact Number *
Results of Screening Questions:
- If the individual answers NO to all questions from 1 through 3 they have passed and can enter the workplace.
- If individual answers YES to any questions from 1 through 3, they have not passed and should be advised that should not enter the workplace (including any outdoor, or partially outdoor, workplaces). They should go home to self-isolate immediately and contact their health care provider or Telehealth Ontario (1-866-797-0000) to find out if they need a COVID-19 test.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms