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COVID-19 ASSESSMENT FORM
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Are you experiencing or have you experienced in the past 10 days any of the following:
Yes
No
Fever
New onset or worsening of cough or other symptoms
New onset or worsening of existing sneezing
Sore throat
Difficulty breathing
Severe Fatigue
Yes
No
Fever
New onset or worsening of cough or other symptoms
New onset or worsening of existing sneezing
Sore throat
Difficulty breathing
Severe Fatigue
Clear selection
Have you traveled to any countries outside Canada (incl. United States) within the last 14 days?
Yes
No
Clear selection
Did you provide care or have close contact with someone who has symptoms of COVID-19 (cough, fever, sneezing, difficulty breathing or sore throat) within the last 14 days?
Yes
No
Clear selection
Did you provide care or have close contact with someone who is being tested for COVID-19 or who has been diagnosed with COVID-19?
Yes
No
Clear selection
If you have answered yes to any of the questions please leave the workplace, notify a supervisor and follow the provincial guidelines and self-assessment tool
https://B.C.thrive.health/
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