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.

Fever or Chills*

Yes	No

Difficulty breathing or shortness of breathing*

Yes	No

Cough*

Yes	No

Sore throat, trouble 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

2. Have you travelled outside of Canada in the past 14 days?

Have you travelled outside of Canada in the past 14 days?*

Yes	No

3. Have you had close contact with a confirmed or probable case of COVID-19?

Have you had close contact with a confirmed or probable case of COVID-19?*

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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