Name: _________________________ Date: _____________
- Do you have any of the following new or worsening symptoms or signs?
|New or worsening Cough||Yes||No|
|Shortness of Breath||Yes||No|
|Runny Nose, sneezing or nasal Congestion||Yes||No|
(in absence of underlying reasons for symptoms such as seasonal allergies and post nasal drip)
|New Smell or taste disorder(s)||Yes||No|
|Nausea / Vomiting, diarrhea, abdominal pain||Yes||No|
2. Have you travelled outside of Canada or had close contact with anyone that has travelled outside of Canada in the past 14 days?
3. Do you have a fever?
4. Have you had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19?
Yes – go to question 5 No – screening complete
5. Did you wear the required and/or recommended PPE according to the type of duties you were performing (e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures (AGMPs)) when you had close contact with a suspected or confirmed case of COVID-19?
Analysis of Results to Screening Questions:
|ABLE TO ENTER THE CLINIC||NOT PERMITTED TO ENTER THE CLINIC|
|AnswersNO to ALL Questions’ 1-4 Answers Yes to Question 4 and 5, and does not have a fever||Answers Yes to ANY Questions’ 1-3 Answers Yes to Question 4, and No to Question 5|
Administered by: ______________________________ Date: ______________