Staff Symptom Monitoring Log
Please fill this form out prior to starting your shift at SBSCFC
First and last name *
Date *
MM
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DD
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YYYY
Work Shift Hours *
Dept. & Location of Work *
PART 1: Do you have any seasonal allergies? If yes, take your allergy medications each day.
PART 2: Symptoms. Do you have the following Symptoms in the last 24 hours? Check if YES.
One (1) or more of the above symptoms in the last 24 hours = stay home, self-isolate and call*
Do you have any of the following other symptoms in the last 24 hours?
Two (2) or more of the above symptoms in the last 24 hours = stay home, self-isolate and call*
PART 3: Household member. Does any member of your household have COVID-19-related symptoms and awaiting a COVID-19 test or test result? If yes, please contact your manager to determine your next steps, self isolate and await their test results. See part 4 for how to advise your manger
PART 4: Decision and Plan
• No symptoms or doesn’t meet criteria for off work: Enter the workplace and start your work shift. Please remember to perform hand hygiene before, throughout and after your shift, and wear a procedure mask at all times.•
• Symptoms that warrant staying home: *Mon-Fri from 8AM-4PM: Call in sick in your usual fashion and inform your manager. Please contact KMHC’s COVID-19 Test Centre (ext.2296) to determine if testing is needed. Leave a message with Staff Health (ext.2226) for follow-up* From 4PM-8AM, and Sat-Sun or holidays: call in sick in your usual fashion. Call the COVID-19 Test Centre (ext.2296) and leave a message with your name, phone number and symptoms Follow up with your manager and Staff Health on the next weekday and indicate whether COVID-19 testing was booked or already done.
If you are experiencing true distress and are very unwell, please call the ambulance.
Your well-being and your mental health is important! If you require support, please speak to a trusted friend or colleague; seek out assistance through KSCS or 811 Psychosocial, or your Employee Assistance program.
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