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Mandatory Employee Screening Measures for North Halton

 

This questionnaire MUST be completed before leaving for work daily 

 

Immediately contact your department head before leaving for work, if you answer "Yes" to any of the following questions 

I Agree

 

 

 

First Employee's Name

First Name*

Last Name*

Phone*
First Employee's Age Acknowledgment*
First Employee's Date of Birth*
I certify that I am 18 years of age or older
First Employee's Screening Questions:

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.

Fever or Chills?*
Yes
No
Difficulty breathing or shortness of breath?*
Yes
No
Cough?*
Yes
No
Sore throat, difficulty swallowing?*
Yes
No
Runny nose, stuffy nose or nasal congestion?*
Yes
No
Decrease or loss of smell or taste?*
Yes
No
Nausea, vomiting, diarrhea, abdominal pain?*
Yes
No
Not feeling well, extreme tiredness, sore muscles?*
Yes
No
Have you travelled outside of Canada in the past 14 days?*
Yes
No
Have you had close contact with a confirmed or probable case of COVID-19?*
Yes
No
First Employee's Signature*
Second Employee's Name

First Name*

Last Name*
Second Employee's Date of Birth*
Second Employee's Screening Questions:

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.

Fever or Chills?*
Yes
No
Difficulty breathing or shortness of breath?*
Yes
No
Cough?*
Yes
No
Sore throat, difficulty swallowing?*
Yes
No
Runny nose, stuffy nose or nasal congestion?*
Yes
No
Decrease or loss of smell or taste?*
Yes
No
Nausea, vomiting, diarrhea, abdominal pain?*
Yes
No
Not feeling well, extreme tiredness, sore muscles?*
Yes
No
Have you travelled outside of Canada in the past 14 days?*
Yes
No
Have you had close contact with a confirmed or probable case of COVID-19?*
Yes
No
Third Employee's Name

First Name*

Last Name*
Third Employee's Date of Birth*
Third Employee's Screening Questions:

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.

Fever or Chills?*
Yes
No
Difficulty breathing or shortness of breath?*
Yes
No
Cough?*
Yes
No
Sore throat, difficulty swallowing?*
Yes
No
Runny nose, stuffy nose or nasal congestion?*
Yes
No
Decrease or loss of smell or taste?*
Yes
No
Nausea, vomiting, diarrhea, abdominal pain?*
Yes
No
Not feeling well, extreme tiredness, sore muscles?*
Yes
No
Have you travelled outside of Canada in the past 14 days?*
Yes
No
Have you had close contact with a confirmed or probable case of COVID-19?*
Yes
No
Fourth Employee's Name

First Name*

Last Name*
Fourth Employee's Date of Birth*
Fourth Employee's Screening Questions:

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.

Fever or Chills?*
Yes
No
Difficulty breathing or shortness of breath?*
Yes
No
Cough?*
Yes
No
Sore throat, difficulty swallowing?*
Yes
No
Runny nose, stuffy nose or nasal congestion?*
Yes
No
Decrease or loss of smell or taste?*
Yes
No
Nausea, vomiting, diarrhea, abdominal pain?*
Yes
No
Not feeling well, extreme tiredness, sore muscles?*
Yes
No
Have you travelled outside of Canada in the past 14 days?*
Yes
No
Have you had close contact with a confirmed or probable case of COVID-19?*
Yes
No
Fifth Employee's Name

First Name*

Last Name*
Fifth Employee's Date of Birth*
Fifth Employee's Screening Questions:

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.

Fever or Chills?*
Yes
No
Difficulty breathing or shortness of breath?*
Yes
No
Cough?*
Yes
No
Sore throat, difficulty swallowing?*
Yes
No
Runny nose, stuffy nose or nasal congestion?*
Yes
No
Decrease or loss of smell or taste?*
Yes
No
Nausea, vomiting, diarrhea, abdominal pain?*
Yes
No
Not feeling well, extreme tiredness, sore muscles?*
Yes
No
Have you travelled outside of Canada in the past 14 days?*
Yes
No
Have you had close contact with a confirmed or probable case of COVID-19?*
Yes
No
Sixth Employee's Name

First Name*

Last Name*
Sixth Employee's Date of Birth*
Sixth Employee's Screening Questions:

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.

Fever or Chills?*
Yes
No
Difficulty breathing or shortness of breath?*
Yes
No
Cough?*
Yes
No
Sore throat, difficulty swallowing?*
Yes
No
Runny nose, stuffy nose or nasal congestion?*
Yes
No
Decrease or loss of smell or taste?*
Yes
No
Nausea, vomiting, diarrhea, abdominal pain?*
Yes
No
Not feeling well, extreme tiredness, sore muscles?*
Yes
No
Have you travelled outside of Canada in the past 14 days?*
Yes
No
Have you had close contact with a confirmed or probable case of COVID-19?*
Yes
No
Seventh Employee's Name

First Name*

Last Name*
Seventh Employee's Date of Birth*
Seventh Employee's Screening Questions:

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.

Fever or Chills?*
Yes
No
Difficulty breathing or shortness of breath?*
Yes
No
Cough?*
Yes
No
Sore throat, difficulty swallowing?*
Yes
No
Runny nose, stuffy nose or nasal congestion?*
Yes
No
Decrease or loss of smell or taste?*
Yes
No
Nausea, vomiting, diarrhea, abdominal pain?*
Yes
No
Not feeling well, extreme tiredness, sore muscles?*
Yes
No
Have you travelled outside of Canada in the past 14 days?*
Yes
No
Have you had close contact with a confirmed or probable case of COVID-19?*
Yes
No
Eighth Employee's Name

First Name*

Last Name*
Eighth Employee's Date of Birth*
Eighth Employee's Screening Questions:

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.

Fever or Chills?*
Yes
No
Difficulty breathing or shortness of breath?*
Yes
No
Cough?*
Yes
No
Sore throat, difficulty swallowing?*
Yes
No
Runny nose, stuffy nose or nasal congestion?*
Yes
No
Decrease or loss of smell or taste?*
Yes
No
Nausea, vomiting, diarrhea, abdominal pain?*
Yes
No
Not feeling well, extreme tiredness, sore muscles?*
Yes
No
Have you travelled outside of Canada in the past 14 days?*
Yes
No
Have you had close contact with a confirmed or probable case of COVID-19?*
Yes
No
Ninth Employee's Name

First Name*

Last Name*
Ninth Employee's Date of Birth*
Ninth Employee's Screening Questions:

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.

Fever or Chills?*
Yes
No
Difficulty breathing or shortness of breath?*
Yes
No
Cough?*
Yes
No
Sore throat, difficulty swallowing?*
Yes
No
Runny nose, stuffy nose or nasal congestion?*
Yes
No
Decrease or loss of smell or taste?*
Yes
No
Nausea, vomiting, diarrhea, abdominal pain?*
Yes
No
Not feeling well, extreme tiredness, sore muscles?*
Yes
No
Have you travelled outside of Canada in the past 14 days?*
Yes
No
Have you had close contact with a confirmed or probable case of COVID-19?*
Yes
No
Tenth Employee's Name

First Name*

Last Name*
Tenth Employee's Date of Birth*
Tenth Employee's Screening Questions:

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.

Fever or Chills?*
Yes
No
Difficulty breathing or shortness of breath?*
Yes
No
Cough?*
Yes
No
Sore throat, difficulty swallowing?*
Yes
No
Runny nose, stuffy nose or nasal congestion?*
Yes
No
Decrease or loss of smell or taste?*
Yes
No
Nausea, vomiting, diarrhea, abdominal pain?*
Yes
No
Not feeling well, extreme tiredness, sore muscles?*
Yes
No
Have you travelled outside of Canada in the past 14 days?*
Yes
No
Have you had close contact with a confirmed or probable case of COVID-19?*
Yes
No
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Screening Questions:

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.

Fever or Chills?*
Yes
No
Difficulty breathing or shortness of breath?*
Yes
No
Cough?*
Yes
No
Sore throat, difficulty swallowing?*
Yes
No
Runny nose, stuffy nose or nasal congestion?*
Yes
No
Decrease or loss of smell or taste?*
Yes
No
Nausea, vomiting, diarrhea, abdominal pain?*
Yes
No
Not feeling well, extreme tiredness, sore muscles?*
Yes
No
Have you travelled outside of Canada in the past 14 days?*
Yes
No
Have you had close contact with a confirmed or probable case of COVID-19?*
Yes
No
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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