COVID 19 Screening
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Email *
Name *
Today's Date *
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REQUIRED SCREENING QUESTIONS (Question 1)
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.)
Fever or Chills *
Required
Difficulty breathing or shortness of breath *
Required
Cough *
Required
Sore throat, trouble swallowing *
Required
Runny nose / stuff 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 travelled outside of Canada in the past 14 days? (Question 2) *
Required
Have you had close contact with a confirmed or probable cause of COVID-19? (Question 3) *
Required
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 the individual answers YES to any questions from 1 through 3, they have not passed and
should be advised that they 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.
Source
http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/workplace_screening_tool_guidance.pdf
A copy of your responses will be emailed to the address you provided.
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