Daily COVID-19 Screening Form

Screening should occur before or when the worker arrives at the beginning of their workday. The questions in this tool have been defined by the Ministry of Health.

This screening tool can be completed either online or on-site before the worker enters the workplace. Anyone who does not pass screening should not enter the workplace.

Date
Name
Location

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.

  • Continuous Cough, more than usual, making a whistling noise when breathing, not related to other known causes or conditions (for example, asthma, post-infectious reactive airways, COPD)
  • Shortness of breath or difficulty breathing; out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma)
  • Fever or chills (37.8 degrees Celsius/100 degrees Fahrenheit or higher)
  • Muscle aches that are unusual or long lasting; not related to other known causes or conditions (for example, a sudden injury, fibromyalgia)
  • Headache that’s unusual or long lasting; not related to other known causes or conditions (for example, tension-type headaches, chronic migraines)
  • Sore throat; not related to other known causes or conditions (for example, seasonal allergies, acid reflux)
  • New loss of taste or smell; not related to other known causes or conditions (for example, allergies, neurological disorders)
  • Difficulty Swallowing; painful swallowing, not related to other known causes or conditions
  • Extreme tiredness that is unusual; fatigue, lack of energy, not related to other known causes or conditions (for example, depression, insomnia, thyroid dysfunction)
  • Pink Eye; conjunctivitis, not related to other known causes or conditions (for example, reoccurring styes)
  • Runny or stuffy/congested nose; not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather)

Have your travelled outside of Canada in the last 14 days?

Have you been directly in contact with anyone who has COVID-19 in the last 14 days? If you already went for a test and got a negative result, select “No”.