Complete this form prior to entering CoMotion.
Updated on Sunday December 20, 2020

As of 12:01AM on Monday December 21st, The City of Hamilton is in the Grey Lockdown Zone and will be for at least 28 days. We advise all those who can, to stay home wherever possible. If you cannot, or need to come into CoMotion to work, please continue to complete this mandatory screening form for each day that you will be on site at CoMotion.

This screening form must be filled out daily before you enter CoMotion. No exceptions.

If you'd like to learn more about the new lockdown restrictions, learn more here: https://www.thespec.com/news/hamilton-region/2020/12/20/hamilton-is-heading-back-into-lockdown-monday-heres-what-you-need-to-know.html
Your Name (First & Last) *
Today's Date *
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Mandatory Covid-19 Screening Questions
COVID-19 Screening Tool for Workplaces
(Businesses and Organizations)

We are following the Provincial screening tool, which can be found here:
http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/workplace_screening_tool_guidance.pdf

* Please note: If you do not complete this form, you cannot physically work at CoMotion or be in the space at all.

If you answer NO to all questions, you are free to work at CoMotion. If you answer YES to any questions 1 thru 3, you cannot work at CoMotion and must contact your health provider, take the online self-assessment and/or contact Telehealth Canada for next steps.

This form must be completed each day you will physically be at CoMotion.

All staff, coworkers, visitors and vendors must complete this form. No exceptions.
1. Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions. *
Yes
No
Fever or chills
Difficulty breathing or shortness of breath
Cough
Sore throat, trouble swallowing
Runny nose/stuffy nose or nasal congestion
Decrease or loss of smell or taste
Nausea, vomiting, diarrhea, abdominal pain
Not feeling well, extreme tiredness, sore muscles
2. Have you travelled outside of Canada in the past 14 days? *
3. Have you had close contact with a confirmed or probable case of COVID-19? *
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