SWRC Staff Covid-19 Screening Questionnaire Before you come to the office for work or any reason, please answer all of the Covid-19 screening questions below. Thank you.Name*By entering your name, you verify that the answers in this questionnaire are true and that you, personally, have answered them. Thank you. First Last Email* Enter Email Confirm Email Preferred Phone*ExtensionOnly if applicable to the preferred phone number. Date MM slash DD slash YYYY Location*Which regional office will you be entering? Guthrie Toronto Thunder Bay North Bay Enter Time*Approximately what time will you be entering the building. Hours : Minutes AM PM AM/PM Exit Time*Approximately what time will you be leaving the building. Hours : Minutes AM PM AM/PM Symptoms*Do you have any of these new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions. Please select all that apply. I do not have any of these symptoms today. fever/chills cough difficulty breathing/shortness of breath sore throat/difficulty swallowing runny/stuffy nose, or nasal congestion decrease or loss of smell or taste nausea, vomiting, diarrhea, abdominal pain Not feeling well, extreme tiredness, sore muscles skin rash/discolouration on fingers/toes Travel*Have you travelled outside of Canada in the past 14 days? Yes No Close Contact*Have you had close contact with a confirmed or probable case of COVID-19? Yes No Results of Screening Questions: • If you answerd NO to all questions, then you have passed and can enter the workplace. • If you answered YES to any questions, you have not passed and are advised to not enter the workplace (including any outdoor, or partially outdoor, workplaces). Please 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. Please remember to fill out this questionnaire every day before coming onsite. Thank you!CommentsThis field is for validation purposes and should be left unchanged.
