Staff Daily Screening Questionnaire and login

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Please fill the following form daily

Email *

First Name *

Last Name *

Organization *

Todays Date *

YYYY

Time in *

Time

We require you to fill out the below questionnaire to assist in determining your fitness to work or visitation during the COVID-19 pandemic to provide a safe environment for staff, physicians, contractors, patients and families.You must follow hand hygiene protocols and remember to clean your keys, phone, computers and other personal items.The questionnaire only relates to new symptoms or a worsening of symptoms related to allergies, chronic or pre-existing conditions. Those with symptoms related to pre-existing conditions or allergies can still go to work or visit.

Do you have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose? *

Yes

Have you returned to Canada from outside the country (including the USA) in the past 14 days? *

Yes

In the past 14 days, at work or elsewhere, while not wearing appropriate personal protective equipment:

Did you have close contact* with a person who has a probable** or confirmed case of COVID-19? *

Yes

Did you have close contact* with a person who had an acute respiratory illness that started within 14 days of their close contact* to someone with a probable** or confirmed case of COVID-19? *

Yes

Did you have close contact* with a person who had an acute respiratory illness who returned from travel outside of Canada in the 14 days before they became sick? *

Yes

Did you have a laboratory exposure to biological material (i.e. primary clinical specimens, virus culture isolates) known to contain COVID-19? *

Yes

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