Name * E-mail * Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20192020202120222023 Required Screening Questions 1. Are you currently positive for COVID-19, or had contact with a confirmed case, without using the proper PPE? * Yes No 2. Are you awaiting results for a COVID-19 test? * Yes No 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 conditionsa) Fever or chills * Yes No b) Difficulty breathing or shortness of breath * Yes No c) Cough * Yes No d) Sore throat, trouble swallowing * Yes No e) Runny nose/stuff nose or nasal congestion * Yes No f) Decrease or loss of smell or taste * Yes No g) Nausea, vomiting, diarrhea, abdominal pain * Yes No h) Not feeling well, extreme tiredness, sore muscles * Yes No i) Other Cold/Flu like Symptoms * Yes No j) New or Worsening headache * Yes No k) Conjunctivitis/Pink Eye * Yes No 4. Have you travelled outside of Canada in the past 14 days? * Yes No 5. Have you had close contact with a confirmed or probable case of COVID-19? * Yes No Status messageIf 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.