Pre-screening Health Declaration Form (COVID-19)

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.


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.