COVID-19 Screening Questionnaire

(To be completed by any individual (employee, volunteer, client, etc.) entering the practice. Screening should occur before or when a worker enters the practice at the beginning of their day or shift, and before a client or other visitor is admitted inside the practice.)
  • Date Format: MM slash DD slash YYYY
  • Results of Screening Questions:

    -If the individual answers NO to all questions, they have passed and can enter the workplace.
    -If the individual answers YES to any question, they have not passed and should be advised that they should not enter the workplace (including any outdoor, or partially outdoor workplaces). They should go home to self-isolate and contact their health care provider or Telehealth Ontario (1-866-797-0000) to find out if they need a COVID-19 test.