- 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
Difficulty breathing or shortness of breath
Cough
Sore throat, trouble swallowing
Runny nose/stuffy nose or nasal congestion
Decrease or loss of smell or taste
Nausea, vomiting, diarrhea, abdominal pain
Not feeling well, extreme tiredness, sore muscles
No, to all of the above

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

Yes
No

Have you had close contact with a confirmed or probable case of COVID-19?

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)