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