Employee Covid Form This screening tool must be completed before entering the workplace. Anyone who does not pass screening (meaning answers yes to any of the questions) is advised to not enter the workplace and should self-isolate ideally at home, and call their health care provider or Telehealth Ontario (1-866-797-0000) for clinical assessment. 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. Choose any/all that are new, worsening, and not related to other known causes or medical conditions. Your Name Fever and/or chills Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher Yes No Cough or barking cough (croup) Continuous, more than usual, making a whistling noise when breathing, not related to other known causes or conditions (for example, asthma, post-infectious reactive airways, COPD) Yes No Shortness of breath Out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma) Yes No Decrease or loss of smell or taste Not related to other known causes or conditions (for example, allergies, neurological disorders) Yes No Sore throat Not related to other known causes or conditions (for example, seasonal allergies, acid reflux) Yes No Difficulty swallowing Painful swallowing, not related to other known causes or conditions Yes No Pink eye Conjunctivitis, not related to other known causes or conditions (for example, reoccurring styes) Yes No Runny or stuffy/congested nose Not related to other known causes or conditions (for example,seasonal allergies, being outside in cold weather) Yes No Headache that’s unusual or long lasting Not related to other known causes or conditions (for example, tension-type headaches, chronic migraines) Yes No Digestive issues like nausea/vomiting, diarrhea, stomach pain Not related to other known causes or conditions (for example, irritable bowel syndrome, menstrual cramps) Yes No Muscle aches that are unusual or long lasting Not related to other known causes or conditions (for example, a sudden injury, fibromyalgia) Yes No Extreme tiredness that is unusual Fatigue, lack of energy, not related to other known causes or conditions (for example, depression, insomnia, thyroid dysfunction) Yes No Falling down often For older people Yes No