COVID-19 SCREENING FORM FOR TRAINEES & VISITORS COVID-19 SCREENING FORM FOR TRAINEES & VISITORS DateYou are: *TraineeVisitorOther / StaffFirst Name *Last Name *1. Have you travelled outside of Canada in the last 14 days (circle answer)? *YesNo2. Has someone you are in close contact with tested positive for COVID-19 in the last 14 days? *YesNo3. Are you in close contact with a person who is sick with new respiratory symptoms or who recently traveled outside of Canada? *YesNo4. Do you have a fever? (temperature ≥ 37.8 °C) *YesNo4.1 Screener will have employee take temperature5. Do you have any of these symptoms* *ChillsNew or worsening cough (dry or productive)Barking cough (croup)Shortness of breath/difficulty breathingSore throatDifficulty swallowingLoss of taste or smellPink eye (conjunctivitis) Headache that is unusual or long-lastingRunny or stuffy nose (not related to seasonal allergies or other known causes or conditions)Nausea/vomiting/diarrhea/abdominal painMuscle achesUnexplained fatigue/malaiseFalling more than usualOtherNone of the aboveReview If you have answered: NO to all questions – PASS. You may enter the building and proceed as YES to any questions from #1 to #4 – FAIL. Put on a surgical mask, go home immediately and self-isolate. You may work from home if appropriate. YES to #5 only – FAIL. Go to question #6. 6. Are these symptoms typical for you (i.e. history of allergies, migraines, other known medical condition that usually causes these symptoms)? *YES – Please self-isolate. Contact your doctor for a note confirming that symptoms are typical before returning to work.NO – Go home immediately and self-isolate. You may work from home if appropriate.I don't have those symptoms in #5. SignatureStart signing your signature hereYour browser does not support e-Signature field.Note: The list of COVID-19 symptoms is evolving continuously. For an updated list consult www.ontario.ca/coronavirus For instructions on self-isolation and what to do if you have symptoms, visit www.EOHU.ca/coronavirus. Submit FormPlease do not fill in this field.
