Formex Metal - COVID-19 Screening
First Name *
Last Name *
Email Address *
Phone Number *
I am an: *
1. 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. Please indicate "Yes" or "No" to the questions below in the box provided *
Yes
No
Fever or Chills
Difficulty Breathing or Shortness of Breath
Cough
Sore Throat, Trouble Swallowing
Runny Nose/Stuffy Nose or Nasal Congestion Not Due to Allergies
Decrease or Loss of Smell or Taste
Nausea, Vomiting, Diarrhea, Abdominal Pain
Not Feeling Well, Extreme Tiredness, Sore Muscles
Pink Eye
Headache - Long Lasting or Unusual
Muscle Aches - Long Lasting or Unusual
Falling Down Often - For Older People
2. Have you travelled outside of Canada in the last 14 days? *
3. Have you had close contact with a confirmed or probable case of COVID-19? *
4. Do you confirm that these questions have been answered honestly? *
Results of Screening Questions: • If you answered NO to all questions from 1 to 3, you have passed and can enter the workplace. • If you answered YES to any questions from 1 to 3, you have not passed and cannot enter the workplace. If you have not passed the assessment, please email your Manager immediately to notify them of your absence and the results of your screening. You should go home and self-isolate immediately and contact your healthcare provider or Telehealth Ontario (1-866-797-0000) to determine if you require a COVID-19 test. Based on the above, are you safe to enter Formex?
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