COVID-19 SCREENING QUESTIONS Covid-19 Screening "*" indicates required fields Date* MM slash DD slash YYYY Employee Name* First Last 1. Please select any of the following new or worsening symptoms that you currently have? Symptoms should not be chronic or related to other known causes or conditions such as allergies etc.. Fever or chills Difficulty breathing or shortness of breath Cough Sore throat, trouble swallowing Runny nose/stuffy nose or nasal congestion Decrease or loss of smell or taste Nausea, vomiting, diarrhea, abdominal pain Not feeling well, extreme tiredness, sore muscles 2. 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?* Yes No Results of Screening Questions:
