Daily COVID-19 Health Assessment

Name*

First Last

Company*

Location*

Supervisor*

Question 1*

Are you feeling sick or experiencing sudden loss of taste and/or smell? (Examples of feeling sick include but are not limited to a new cough, headache, weakness, fever, difficulty breathing, etc.)

Yes
No

DO NOT report to work. Contact local public health to have symptoms assessed. You may be required to self-isolate OR Monitor. DO NOT report to work until symptoms disappear, or the Health Line says that you are fit to return to work We hope you feel better soon.

Question 2*

Have you been instructed by a public health official to Self-Monitor or to self-isolate?

Yes
No

Please continue to follow instructions by public health officials. If your job allows virtual work, you are able to work from home. Otherwise DO NOT physically report to your work location.

Question 3*

Have you returned from international travel within the past 14 days?

Yes
No

Please refrain from physically reporting for work for 14 days from the date you returned to Canada. If your job allows, you are able to work remotely from home while following guidance of Public Health. Watch for symptoms of illness and monitor, contact local Public Health Agency if symptoms emerge.

Question 4*

Have you had close contact* with an individual that has a confirmed or a probable diagnosis of COVID-19 within the past 14 days? * Close contact means: a) Within two (2) meters for more than fifteen (15) minutes, other than in a management approved work arrangement; or b) Anyone living in the same household.

Yes
No

DO NOT physically report to work for 14 days from the date of exposure. If your job allows, you are able to work remotely from home while following guidance of Public Health. Watch for symptoms of illness and monitor, contact local Public Health Agency if symptoms emerge.

Daily COVID-19 Health Assessment

Fit For Duty