COVID-19 Workplace Screening

1. Do any of the following apply to you?
• I am fully vaccinated* against COVID-19 (it has been 14 days or more since your final dose of either a two-dose or a one-dose vaccine series)
• I have tested positive for COVID-19 in the last 90 days (and since been cleared by the local public health unit)

Personal health information is not collected when you complete this screening tool. The purpose of this question is to provide accurate isolation instructions, which are based on vaccination status.

* A person is fully vaccinated against COVID-19 if,
(a) they have received,
(i) the full series of a COVID-19 vaccine authorized by Health Canada, or any combination of such vaccines,
(ii) one or two doses of a COVID-19 vaccine not authorized by Health Canada, followed by one dose of a COVID-19 mRNA vaccine authorized by Health Canada, or
(iii) three doses of a COVID-19 vaccine not authorized by Health Canada; and
(b) they received their final dose of the COVID-19 vaccine at least 14 days before seeking access to the premises.

Please select YES or NO. If "YES" questions 6, 7 and 8 are not required. *

YES NO

2. Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions.
The symptoms listed here are the symptoms most commonly associated with COVID-19. If you have these symptoms, you should isolate and seek testing.
Please note that rapid antigen testing is not to be used for those with symptoms of COVID-19 or for contacts of known COVID-19 cases.

Please select YES or NO. *

YES NO

Fever and/or chills
Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
Cough or barking cough (croup)
Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have
Shortness of breath
Not related to asthma or other known causes or conditions you already have
Decrease or loss of smell or taste
Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have
(For adults > 18 years or older)
Fatigue. lethargy, malaise and/or muscle aches/joint paint
Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)
If you received a COVID-19 vaccination in the last 48 hours and are only mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”
(For children < 18 years)
Nausea, vomiting and/or diarrhea
Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have

3. In the last 14 days, have you traveled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)? *

YES NO

4. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing. *

YES NO

5. 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

6. In the last 10 days, have you been identified as a "close contact" of someone who currently has COVID-19? If public health has advised you that you do not need to self-isolate, select "No." *

YES NO

7. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? If you have since tested negative on a lab-based PCR test, select "No." *

YES NO

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

Children (less than 18 years of age): fever and/or chills; cough or barking cough; shortness of breath; decrease or loss of taste or smell; nausea, vomiting and/or diarrhea

Adults (greater than 18 years of age): fever and/or chills; cough or barking cough; shortness of breath; decrease or loss of taste or smell; tiredness; muscle aches.

If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing only mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”

Please select YES or NO. *

YES NO

Results of Screening Questions:
• If the worker answered NO to all questions from 2 through 8, they can enter theworkplace. In the workplace, the worker must continue to follow all public health and workplace control measures, including masking, maintaining physical distance and hand hygiene.
o In addition to following all the workplace’s regular control measures, if the worker has received a COVID-19 vaccination in the last 48 hours and has mild fatigue, muscle ache and/or joint pain that only began after immunization, and no other symptoms, the worker must wear a surgical/procedure mask for their entire shift at work even if not otherwise required to do so. Their mask may only be removed to consume food or drink and must remain at least two metres away from others when their mask has been removed. If the symptoms worsen, continue past 48 hours, or if they develop other symptoms, they should leave work immediately to self-isolate and seek COVID-19 testing.
• If the worker answered YES to any questions from 2 through 8, they must not enter the workplace (including any outdoor or partially outdoor workplace). They should inform their employer of this result and go or stay home to self-isolate immediately and contact their health care provider or Telehealth Ontario (1-866-797-0000) to get advice or an assessment, including if they need a COVID-19 test.
• If the worker answered YES to question 8, they must be advised to stay home, along with the rest of the household, until the sick individual gets a negative COVID-19 result on a valid PCR test (e.g., lab-based PCR or a rapid molecular test, such as ID Now), is cleared by their local public health unit, or is diagnosed with another illness. Rapid antigen testing cannot not to be used test those with symptoms of COVID-19 or for contacts of known COVID-19 cases.
• If any of the answers to these screening questions change during the day, the worker should inform their employer of the change and go home to self-isolate immediately and contact their health care provider or Telehealth Ontario (1-866-797-0000) to get advice or an assessment, including if they need a COVID-19 test.
• Businesses and organizations must maintain a record of the date/time that workers were in the workplace and their contact information. This information may be requested by public health for contact tracing. These records should be maintained for a period of at least a month.
• Any record created as part of worker screening may only be disclosed as required by law.

Note:
• For those workers whose work responsibilities involve traveling to multiple locations as part of their work day or shift (e.g., delivery truck drivers, take-out, grocery, prescription delivery staff, etc.), it is the responsibility of the worker’s employer to conduct the screening and not that of the receiving business organization or individual. However, such screening may not exempt a worker from being screened by another organization/workplace if the worker is seeking entry into different types of premises (e.g., food deliveries to a long-term care home, and to other places or households).

Resources:
• COVID-19 (coronavirus) in Ontario webpage (find a testing location, check your results, how to stop the spread of the virus).
• Ministry of Labour, Training and Skills Development’s Resources to prevent COVID-19 in the workplace.
• Screening for COVID-19: guidance for employers webpage.
• COVID-19 vaccines and workplace health and safety webpage.

Name *

First Name Last Name

Phone Number *

Please enter a valid phone number.

Email *

example@example.com

COVID-19 Screening Questionnaire