COVID-19 Employee Screening
Please take a few moments to fill out this form. You must complete the screening before entering the office.
If anyone in your household has been diagnosed with COVID-19, has symptoms, or is awaiting test results, all non-vaccinated individuals from the household must stay home until the person with symptoms has a negative COVID-19 test result, or is cleared by a medical or public health official.
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What's your full name?
What's your email address?
Project name or office
Are you currently experiencing any of these symptoms? (Not as a result of asthma, allergies, COVID-19 vaccine side effects, or any other known causes or conditions)
Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
Difficulty breathing or shortness of breath - Out of breath, unable to breathe deeply
Cough that is new or worsening
Sore throat or difficulty swallowing
Runny, stuffy or congested nose
Decrease or loss of taste or smell
Nausea, vomiting, diarrhea, stomach pain
Headache that's unusual, extreme tiredness, sore muscles
Sluggishness or lack of appetite
None of the above
Have you travelled outside of Canada in the past 14 days?
In the last 14 days, have you been in close physical contact with someone who is showing symptoms, currently has COVID-19 in their system or returned from travelling outside of Canada?
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This form was created inside of Him & Her Incorporated.