COVID-19 Self Screening Questionnaire
You must answer “NO” to all the questions in this questionnaire in order to come to your designated worksite. If you answer “YES” to any of the questions, you must self-isolate until you receive further instruction from corresponding health authorities AND notify your supervisor, manager, or HR representative regarding your absence.
Are you experiencing any of the following?
YesNo
Have you traveled to any countries outside of Canada (including the United States) within the last 14 days?
Travel includes passing through an airport outside of Canada.
Within the last 14 days did you provide care or have close contact with a symptomatic person known or suspected to have COVID-19?
A close contact is defined as a person who:
Have you had close contact with a person who traveled outside of Canada in the last 14 days who have become ill (fever, cough, sore throat, runny nose or headache)?
Rev. 01.0 October 2020
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Document Name: COVID-19 Self Screening Questionnaire
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