Hawk River Construction Daily COVID-19 Screening

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:

Do not enter if you have answered YES to any of the following questions.

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

Revised: March 13, 2021
Email address *
Name (First and Last): *
Are you currently experiencing any of these symptoms? Make known any/all that are NEW or WORSENING, and not related to other known causes or conditions you already have: FEVER AND/OR CHILLS, COUGH OR BARKING COUGH (CROUP), SHORTNESS OF BREATH, SORE THROAT, DIFFICULTY SWALLOWING, RUNNY OR STUFFY NOSE, DECREASED OR LOSS OF TASTE OR SMELL, PINK EYE, HEADACHE, NAUSEA, VOMITING, DIARRHEA, STOMACH PAIN, MUSCLE ACHES, EXTREME TIREDNESS, FALLING DOWN OFTEN? *
1 point
Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *
1 point
In the last 14 days, have you or anyone you live with travelled outside of Canada? *
1 point
In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19? *
1 point
Has a doctor, health care provider or public health unit told you that you should currently be isolating? *
1 point
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? *
1 point
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