This form MUST be completed by all Hawk River employees and visitors PRIOR to entry of: office, jobsite and equipment as per Ontario Regulation 364/20.

It is not to be used as a clinical assessment tool or intended to take the place of medical advice, diagnosis or
treatment. Where the document includes references to legal requirements, it is not to be construed as legal advice.

This form applies to all workers, subcontractors and visitors entering the work environment. It excludes
emergency services or other first responders entering a workplace for emergency purposes.

Screening should occur before or when a worker enters the workplace at the beginning of their day or shift, or when an essential visitor arrives.

At a minimum, the following questions should be used to screen individuals for COVID-19 before they are permitted entry into the workplace (business or organization).



Instructions should be as followed:

Upon completion, you will get a score out of 3. Any individual who does not get a score of 3/3 NOT enter.

Once an individual has passed the screening questions, they may enter the workplace, but should report any changes/symptoms immediately.

When in doubt, stay home and contact your health care provider, and/or contact Telehealth Ontario (1 866-797-0000), and/or take the Ontario Self Assessment https://covid-19.ontario.ca/self-assessment/.


Questions marked with an asterisk (*) are required.


Reference: This form is a modified version of the Government of Ontario's COVID-19 Screening Tool for Workplaces, which can be found at the following link: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/workplace_screening_tool_guidance.pdf