Staff Symptom Monitoring Log
Please fill this form out prior to starting your shift at SBSCFC
First and last name
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.
New cough or worsening chronic cough
Fever / Chills
Sudden lack of taste or smell without nasal congestion
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?
New onset headache
New onset pain (muscular, chest, abdomen, joints) not related to exercise
New intense fatigue
New severe loss in appetite
A gastrointestinal symptom (diarrhea, nausea or vomiting)
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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