Employee Screening Form

Employee Screening Form

The purpose of this Screening Tool is to help you make decisions about whether you should attend school or go to work.

This screening tool should be completed daily before attending school or work. No personal information is requested when completing the tool, which means that you cannot be personally identified or linked to your responses. Using this tool is voluntary. It is recommended that you contact a healthcare provider if you have more questions about your health. This tool is subject to change as further guidance from the Ministry of Health and evidence related to COVID-19 risks becomes available.

Please note: A variety of factors (including underlying health conditions) can increase the risk of serious illness from COVID-19, and general guidance may not always apply well to individual situations. Every individual needs to take into account their personal risk factors when deciding whether it is safe for them to attend or work in a particular place. OPH recommends the CDC website to all persons wishing to better understand their personal risks from COVID-19 infection.

  • As of the time of completing this form.
  • Ex: Cough, fever, difficulty breathing, runny nose.
  • This can be because of an outbreak or contact tracing.
  • Choose any/all that are new, worsening, and NOT related to other known causes or conditions.
  • *Close contact means:
    • Being within 2 metres (6 feet) of a person; the longer they were within 2 metres, the higher the risk. Interactions where people briefly come within 2 metres (6 feet) of each other, such as walking by someone in the hallway or on the street, are generally not considered close contacts.
    • Living within the same household or providing care to a person (e.g., bathing, feeding, or dressing), without the use of Personal Protective Equipment (PPE) appropriate to the setting AND/OR where there were breaches or contamination of PPE (e.g., improper or inconsistent use of medical facemask and eye protection).
    • Physical contact (e.g., shaking hands, hugging, kissing, being sneezed or coughed on)