COVID-19 Screening Form

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In order to comply with O. Reg. 364/20: Rules for Areas at Step 3 made under the Reopening Ontario (A Flexible Response to COVID-19) Act, 2020 (ROA) all clients and employees are required to review and answer the below questions. The information in this form is used solely for compliance purposes and will not be used for any other reason.

First Name

Last Name

Phone Number *

Do you have any of the following new or worsening symptoms?

Fever/Chills

Cough

Difficulty breathing/Shortness of breath

Sore throat/Difficulty swallowing

Stuffy/Runny nose (unrelated to seasonal allergies)

Loss of taste or smell

Headache, extreme tiredness, muscle aches/ joint pain (not related to getting a COVID-19 vaccine in the last 48 hours)

Nausea, vomiting, diarrhea, stomach pain

By checking the box below you acknowledge that there is a risk of contracting COVID-19 in Personal Care Services such as those offered by IVONNE. *

I Agree

Required

If you answered YES to any of the questions above, please return home and self-isolate. Visit OttawaPublicHealth.ca/COVIDCentre for more information about getting tested. If you are feeling unwell, contact your health care provider or call Telehealth Ontario at 1-866-797-0000 to speak to a registered nurse. Adapted from Ottawa Public Health.

https://ivonnesanchez.com/coronavirus
Updated November 1, 2021

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