ClimateCare Employee Self-Screening Tool

Company Name*

Employee Name*

Required Screening Questions

Please use this self-assessment tool to determine if you will be permitted entry into the workplace.

Note: The results of this questionnaire will be delivered to your employer for their records.

1. 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.

For individuals who are 18 years of age and older:

Fever or Chills*

Yes	No

Cough or barking cough (croup)*

Yes	No

Shortness of breath*

Yes	No

Sore throat*

Yes	No

Difficulty swallowing*

Yes	No

Decrease or loss of smell or taste*

Yes	No

Pink eye*

Yes	No

Runny or stuffy/congested nose*

Yes	No

Headache*

Yes	No

Digestive issues like nausea/vomiting, diarrhea, stomach pain*

Yes	No

Muscle aches/joint pain*

Yes	No

Fatigue*

Yes	No

Falling down often*

Yes	No

2. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?*

Yes	No

3. In the last 10 days, have you tested positive on a rapid antigen test or a homebased self-testing kit?

In the last 10 days, have you tested positive on a rapid antigen test or a homebased self-testing kit?*

Yes	No

4. In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?

In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?*

Yes	No

5. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?

In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?*

Yes	No

6. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?

In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?*

Yes	No

7. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?*

Yes	No

This questionnaire has been adapted from Ontario Public Health Guidelines.

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ClimateCare Employee Self-Screening Tool

Required Screening Questions

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