COVID-19 Self Screening Questionnaire-Staff

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

All CPES Staff MUST use this questionnaire daily to decide if you should come to work.

Risk Assessment: Initial Screening Questions

Name *

1) Do you have any of the below symptoms: *

Yes

Fever

Cough

Shortness of Breath / Difficulty Breathing

Sore throat

Chills

Painful swallowing

Runny Nose / Nasal Congestion

Feeling unwell / Fatigued

Nausea / Vomiting / Diarrhea

Unexplained loss of appetite

Loss of sense of taste or smell

Muscle / Joint aches

Headache

Conjunctivitis (Pink Eye)

2) Have you, or anyone in your household, returned from travel outside of Canada in the last 14 days? *

Yes

3) Have you had close UNPROTECTED contact (face-to-face contact within 2 metres) with someone who is ill with cough and/or fever? *

Yes

4) Have you or anyone in your household been in close UNPROTECTED contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19? *

Yes

* "UNPROTECTED" means close contact without appropriate personal protective equipment (PPE).

If you have answered "YES" to any of the above questions, please DO NOT enter the school at this time. You should stay home and use the COVID-19 Self-Assessment Tool to determine whether you need to be tested for COVID-19.
https://covid-19.ontario.ca/self-assessment/

If you have answered "NO" to all the above questions, you may attend school.

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

Forms