Covid Screening Tool
Home
Privacy
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
Sore throat, Difficulty swallowing
Yes
No
Runny or stuffy/congested nose
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
Nausea, vomiting, diarrhea, abdominal pain
Yes
No
Headache (not related to getting the COVID-19 vaccine in the last 48 hours).
Yes
No
2. In the last 10 days, has someone you live with: a) Been sick with symptoms associated with COVID-19 and/or b) Tested positive for COVID-19 (on a rapid antigen test or PCR)?
Yes
No
3. In the last 10 days, have you tested positive on a rapid antigen test or home-based self testing kit?
Yes
No
4. In the last 10 days, have you received a COVID Alert exposure notification on your cell?
Yes
No
5. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19? (Confirmed by a rapid antigen test or PCR test)?
Yes
No
6. In the last 14 days, have you travelled outside of Canada? If exempt from Federal quarantine requirements by the border agent at point of entry (IE. You have two or more doses of a COVID-19 vaccine and have met the specific conditions or an essential worker who crosses the Canada-US border regularly for work), 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
Sore throat, Difficulty swallowing
Yes
No
Runny or stuffy/congested nose
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
Nausea, vomiting, diarrhea, abdominal pain
Yes
No
Headache (not related to getting the COVID-19 vaccine in the last 48 hours).
Yes
No
2. In the last 10 days, has someone you live with: a) Been sick with symptoms associated with COVID-19 and/or b) Tested positive for COVID-19 (on a rapid antigen test or PCR)?
Yes
No
3. In the last 10 days, have you tested positive on a rapid antigen test or home-based self testing kit?
Yes
No
4. In the last 10 days, have you received a COVID Alert exposure notification on your cell?
Yes
No
5. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19? (Confirmed by a rapid antigen test or PCR test)?
Yes
No
6. In the last 14 days, have you travelled outside of Canada? If exempt from Federal quarantine requirements by the border agent at point of entry (IE. You have two or more doses of a COVID-19 vaccine and have met the specific conditions or an essential worker who crosses the Canada-US border regularly for work), select “No”.
Yes
No
Submit
Submit