Employee Name
*
First Name
Last Name
Work Date
-
Month
-
Day
Year
Date
Are you currently experiencing any of these symptoms?
*
Fever and/or chills
Cough or barking cough (croup)
Shortness of breath
Sore throat
Difficulty swallowing
Runny or stuffy/congested nose
Decrease or loss of taste or smell
Pink eye
Headache
Digestive issues like nausea/vomiting, diarrhea, stomach pain
Muscle aches
Extreme tiredness
Falling down often
None of the above
In the last 14 days, have you travelled outside of Canada?
*
Yes
No
In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?
*
Yes
No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
*
Yes
No
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?
*
Yes
No
Signature
*
Submit
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