Employee/Workplace Questionnaire

Name *

E-mail *

Date

Month

Day

Year

Required Screening Questions

1. Are you currently positive for COVID-19, or had contact with a confirmed case, without using the proper PPE? *

Yes

2. Are you awaiting results for a COVID-19 test? *

Yes

3. 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

a) Fever or chills *

Yes

b) Difficulty breathing or shortness of breath *

Yes

c) Cough *

Yes

d) Sore throat, trouble swallowing *

Yes

e) Runny nose/stuff nose or nasal congestion *

Yes

f) Decrease or loss of smell or taste *

Yes

g) Nausea, vomiting, diarrhea, abdominal pain *

Yes

h) Not feeling well, extreme tiredness, sore muscles *

Yes

i) Other Cold/Flu like Symptoms *

Yes

j) New or Worsening headache *

Yes

k) Conjunctivitis/Pink Eye *

Yes

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

Yes

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

Yes

Status message

If the individual answers No to all questions from 1 through 5, they have passed and can enter the workplace.

Error message

If the individual answers Yes to any questions from 1 through 5, they have not passed and should be advised that they should not enter the workplace(including any outdoor, or partially outdoor, workplaces). They should go home to self-isolate immediately and contact their health care provider or Telehealth Ontario(1 866-797-0000) to find out if they need a COVID-19 test.

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GEORGINA SOD & LANDSCAPE LIMITED

905-473-7000 | info@georginasod.com | Contact us!

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Employee/Workplace Questionnaire

Status message

Error message

GEORGINA SOD & LANDSCAPE LIMITED