COVID-19 Self Assessment Form
Please complete this form each day BEFORE you go to work for your scheduled shift. This form must be completed as your acknowledgement that you are not experiencing any symptoms of COVID-19 and you are eligible to attend work. If you must answer "Yes" to any of the questions below, DO NOT GO TO WORK. Call your supervisor to advise that you will not be attending work based on the answers to this questionnaire. Human Resources will contact you as soon as possible to discuss the situation.
Email *
What is your first and last name? *
Today's Date *
MM
/
DD
/
YYYY
Current time *
Time
:
What location do you work in? *
Do you have any of the following symptoms? *
Yes
No
New or worsening cough?
Shortness of breath or difficulty breathing?
Temperature equal to or over 38C?
Feeling feverish?
Chills?
Muscle or body aches?
New loss of smell or taste?
Headache?
Gastrointestinal symptoms? (pain, diarrhea, vomitting)
Feeling very unwell?
Contact questions *
Yes
No
Have you travelled outside of the country in the last 14 days?
Within the last 14 days did you provide care or have close contact with a symptomatic person known or suspected to have COVID-19?
Did you have close contact with a person who travelled outside of Canada in the last 14 days who has become ill?
Have you or anyone in your household been advised by a physician or public health authority to quarantine for 14 days?
A copy of your responses will be emailed to the address you provided.
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