Workplace Screening form
for COVID-19

Good Morning Ian

Please answer all of the below questions truthfully. (All questions are required)

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.

1. Fever or chills
2. Difficulty breathing or shortness of breath
3. Cough
4. Sore throat, trouble swallowing
5. Runny nose/stuffy nose or nasal congestion
6. Decrease or loss of smell or taste
7. Nausea, vomiting, diarrhea, abdominal pain
8. Not feeling well, extreme tiredness, sore muscles

Have you?

9. Travelled outside of Canada in the past 14 days?
10. Had close contact with a confirmed or probable case of COVID-19?

Results

To complete the form, choose a result in the below selection and enter your name. If any questions are missed you will be returned to this form to complete it.

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