Request edit access
JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
THIS IS A SAMPLE FORM - PLEASE DO NOT EDIT THIS FORM - MAKE A COPY OF THIS FORM AND THEN EDIT YOUR COPY -----COVID-19 Questionnaire for Staff & Guests
We are screening all staff and guests for potential risk of COVID-19 on a daily basis. Please complete the following information when entering the building.
If you have any of the symptoms described below, please do not proceed to the office. We recommend that you stay home to protect the health and safety of the people you work with. You could be carrying and spreading the virus without knowing it.
Follow the advice of your local public health unit or a health care provider.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
I am a:
*
Staff member
Guest
Other:
Name (First and Last)
*
Your answer
In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?
*
Yes
No
In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit? If you have since tested negative on a lab-based PCR test, select "No."
*
Yes
No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
*
Yes
No
Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?
*
Yes
No
Have you had a recent COVID-19 test and are awaiting results?
*
Yes
No
Please click the boxes if you are experiencing any of the following symptoms. If you are not experiencing any symptoms, check None of the above. If you are experiencing any of the symptoms below, please do not come to the LO office, consult with a medical professional, and notify your team leader.
*
Shortness of breath - out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)
Fever and/or chills - temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
Decrease or loss of taste or smell - not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have
Cough that's new or worsening (continuous, more than usual)
Cough or barking cough (croup) - continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)
Extreme tiredness - unusual, fatigue, lack of energy (not related to getting a COVID-19 vaccine in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)
Stuffy or congested nose (not related to seasonal allergies or other known causes or conditions)
Muscle aches/joint pain - unusual, long-lasting (not related to getting a COVID-19 vaccine in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)
None of the above
Required
Additional Comments
Your answer
Date
*
MM
/
DD
/
YYYY
I am a:
*
Staff member
Guest
Other:
Name (First and Last)
*
Your answer
In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?
*
Yes
No
In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit? If you have since tested negative on a lab-based PCR test, select "No."
*
Yes
No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
*
Yes
No
Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?
*
Yes
No
Have you had a recent COVID-19 test and are awaiting results?
*
Yes
No
Please click the boxes if you are experiencing any of the following symptoms. If you are not experiencing any symptoms, check None of the above. If you are experiencing any of the symptoms below, please do not come to the LO office, consult with a medical professional, and notify your team leader.
*
Shortness of breath - out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)
Fever and/or chills - temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
Decrease or loss of taste or smell - not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have
Cough that's new or worsening (continuous, more than usual)
Cough or barking cough (croup) - continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)
Extreme tiredness - unusual, fatigue, lack of energy (not related to getting a COVID-19 vaccine in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)
Stuffy or congested nose (not related to seasonal allergies or other known causes or conditions)
Muscle aches/joint pain - unusual, long-lasting (not related to getting a COVID-19 vaccine in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)
None of the above
Required
Additional Comments
Your answer
Send me a copy of my responses.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Landscape Ontario.
Does this form look suspicious?
Report
Forms
Help and feedback
Help Forms improve
Report
