COVID-19 Screening Form | Champ Engineering limited

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.

For individuals who are 18 years of age and older.

Do you have one or more of the following symptoms?

Yes

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.

Sore throat

Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have

Difficulty swallowing

Painful swallowing not related to 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

Pink eye

Conjunctivitis (not related to reoccurring styles or other known causes or conditions you already have)

Runny or stuffy/congested nose

Not related to seasonal allergies, being outside in cold weather or other known causes or conditions you already have

Headache

Unusual, long lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)

Digestive Issues like nausea/vomiting, diarrhea, stomach pain

Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have

Muscle aches

Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have)

Extreme tiredness

Unusual fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

Falling down often

For older people

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

Yes

In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?

Yes

In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?

If you already went for a test and got a negative result, select "NO"

Yes

In the last 14 days, have you or anyone you live with travelled
outside of Canada?

If you or anyone you live with are exempted from federal quarantine as per Group Exemptions, Quarantine Requirements under the Quarantine Act, select “NO”.

Yes

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

Yes

If you answered NO to all questions from 1 through 6, you can enter the workplace.

If you have answered YES to any of the questions from 1 through 6, you will not be permitted to enter the workplace (including any outdoor, or partially outdoor, workplaces). You should inform your employer of this result and go or stay at home to self-isolate immediately and contact your health care provider or Telehealth Ontario (1 866-797-0000) to get advice or an assessment, including if you need a COVID-19 test.

If you answered YES to Question 6, you must stay at home, along with the rest of the household, until the sick individual gets a negative COVID-19 test result, is cleared by your local public health unit, or is diagnosed with another illness.

If any of the answers to these screening questions change during the day, you must inform your employer of the change and go home to self-isolate immediately and contact your health care provider or Telehealth Ontario (1 866-797-0000) to get advice or an assessment, including if you need a COVID-19 test.