UA Local/JTAC Staff Daily Self Assessment

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The purpose of this assessment is to take all precautionary measures possible to ensure the safety of all staff. We trust that you will truthfully comply with filling out this assessment to self identify if you potentially have been in contact with anyone who may have or has tested positive for COVID-19.

Please refer to the Return to Work Policies and Procedures for further information.

First Name *

Last Name *

Do you have any of these symptoms that are outside of what would be normal for you? Choose any/all that are new, worsening, and not related to other known causes or conditions. *

Fever

Chills

Cough that's new/worsening or barking cough

Shortness of breath

Sore throat

Difficulty swallowing

Runny/stuffy/congested nose

Decrease/loss of taste or smell

Pink eye or conjunctivitis

Headache that's unusual or long lasting

Digestive issues like nausea/vomiting, diarrhea, stomach pain

Muscle aches that are unusual or long lasting

Extreme tiredness that is unusual

NONE OF THE ABOVE

Required

Have you travelled outside of Canada in the last 14 days? *

YES

In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19? *

YES

In the last 14 days, have you been in close physical contact with someone who is currently sick with a new cough, fever, difficulty breathing, or other symptoms associated with COVID-19, or returned from outside of Canada in the last 2 weeks? *

YES

Note: Close physical contact means being less than 2 metres away in the same room, workspace, or area, or living in the same home or being in the same classroom.

Have you read and understood the requirements of the vaccine policy? *

YES

Have you had COVID within the past 90 days? *

YES

Have you had a negative COVID test within the past 72 hours? *

YES

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