- Answerplus

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. *

Fever or Chills
Cough or barking cough (croup)
Shortness of breath
Sore throat. (Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have)
Difficulty swallowing - (Painful swallowing (not related to other known causes or conditions you already have)
Runny or stuffy/congested nose 9 (Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have)
Decrease or loss of taste or smell - (Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have)
Pink eye - (onjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)
Headache - (Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)
Digestive issues like nausea/vomiting, diarrhea, stomach pain - (Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have)
Muscle aches - (Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have)
Extreme tiredness - (Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)
Falling down often - (For older People)
None of the above

In the last 14 days, have you travelled outside of Canada? *

Yes
No

In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?

Yes
No

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

Yes
No

In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?

Yes
No

If all of the above answers are NO, you may proceed to enter the workplace. If you begin to experience symptoms during working hours, please report this to your manager immediately.

If you answered Yes to any of the questions above, you will NOT be permitted to enter the workplace. Please go home to self-isolate immediately and contact your health care provider or Telehealth Ontario (1-866-797-0000) to find out if you need a COVID-19 test.

This is a reminder to adhere to the safe distancing rules, wear your required personal protective equipment, and practice safe hygiene.

Confirmation

I, the undersigned, confirm that I have completed this form in good faith and certify that all information in this form is true and correct to the best of my knowledge. I understand that entering the workplace if I have been potentially exposed to COVID-19 poses a grave risk to the health and wellness of others.

Name *

First

Last

Phone - Visitors Only

Office Location *

HAMILTON
EDMONTON
MONTREAL
TORONTO

Pre-screening Health Declaration Form (COVID-19)