Worker Daily Self-Assessment
This form must be completed on a daily basis and submitted before 8 am for every day. If you answer NO to every question, you may come to work.
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Staff name (first and last) *
Are you experiencing any of the following symptoms? If you answer yes to any of the following symptoms, call 911 or go directly to the nearest Emergency department. *
Required
Are you experiencing any of the following symptoms or combination of symptoms? If you answer yes to any of the above, do not report to work. Notify your manager of supervisor of illness. *
Required
Have you travelled outside of Canada in the last 14 days *
Are you in close contact with someone who has COVID-19? *
Are you in close contact with a person who is sick with respiratory symptoms (fever, cough or difficulty breathing? *
If you answered YES to any of the above, speak to your manager or supervisor. You will need to self isolate for 14 days or until 24 hours after the symptoms have fully resolved, whichever is longer.
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