COVID-19 Screening Checklist
All visitors and employees must fill out the form each day prior to entering the DBOT building.
Name (first and last) *
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
Have you been in close contact with anyone who is sick or has confirmed COVID-19 in the past 14 days? *
Have you been outside Canada in the past 14 days? *
If you answered NO to all questions you have passed and can enter DBOT/Biz Hub •If you answered YES to any questions from 1 through 3, you have not passed and should be advised that you should not enter. Please go home to self-isolate immediately and contact your health care provider or Telehealth Ontario (1 866-797-0000)to find out if they need a COVID-19 test.
I confirm that I have answered this screening truthfully and to the best of my abilities, *
MM
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YYYY
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