COVID-19 Screening Tool for Workplaces

Name:
Shift Start Time:
Shift End Time:

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.

2. Have you travelled outside of Canada in the past 14 days?

3.In the last 14 days, has a public health unit identified you as a close contact of someone who currently has COVID-19?

4. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

5. In the last 14 days, have you received a COVID Alert exposure notification on your cell? If you already went for a test and got a negative result, select “No.”

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