Covid Screening Tool
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First Name:
Last Name:
Company:
WFS
Other
Department:
Accounting
Ruminant Team
Swine Team
Poultry Team
Production
Transport
IT
Purchasing
Customer Service/QC
HR/Safety
Senior Manager
Maintenance/Boiler
Monkton
Company Name:
Contact Number:
Vaccination Status:
Fully Vaccinated (14 days since 2nd dose)
Unvaccinated
Prefer not to say
1. Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.
Fever or chills
Yes
No
Shortness of breath
Yes
No
Cough or barking cough (croup)
Yes
No
Decrease or loss of smell or taste
Yes
No
Muscle aches/joint pain (not related to getting the COVID-19 vaccine in the last 48 hours)
Yes
No
Extreme tiredness (not related to getting the COVID-19 vaccine in the last 48 hours)
Yes
No
2. In the last 14 days, have you travelled outside of Canada and been told to quarantine (per the federal quarantine requirements)?
Yes
No
3. Has a doctor, health care provider or public health unit told you that you should currently be isolating (Staying at home)?
Yes
No
4. In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? If you have since tested negative on a lab-based PCR test, select “No”.
Yes
No
1. Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.
Fever or chills
Yes
No
Shortness of breath
Yes
No
Cough or barking cough (croup)
Yes
No
Decrease or loss of smell or taste
Yes
No
Muscle aches/joint pain (not related to getting the COVID-19 vaccine in the last 48 hours)
Yes
No
Extreme tiredness (not related to getting the COVID-19 vaccine in the last 48 hours)
Yes
No
2. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms that are unrelated to getting a COVID-19 vaccination in the last 48 hours (mild headache, fatigue, muscle aches and/or joint pain). If you are fully vaccinated, select “No”.
Yes
No
3. In the last 14 days, have you travelled outside of Canada and been told to quarantine (per the federal quarantine requirements)?
Yes
No
4. In the last 10 days, has a public health unit identified you as a close contact of someone who currently has COVID-19?
Yes
No
5. Has a doctor, health care provider or public health unit told you that you should currently be isolating (Staying at home)?
Yes
No
6. In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? If you have since tested negative on a lab-based PCR test, select “No”.
Yes
No
7. In the last 14 days, have you received a COVID Alert exposure notification on your cell? If you already went for a test and got a negative result, select “No”.
Yes
No
Submit
Submit