Skip to content

Employee COVID Survey

Employee COVID Survey

Required Screening Questions

Do you have any of the following new or worsening symptoms or signs? Symptomsshould not be chronic or related to other known causes or conditions

- Step 1 of 5

Name *

First

Last

Email

Date / Time

Date

Time

Fever or chills *

Difficulty breathing or shortness of breath *

Cough *

Sore throat, trouble swallowing *

Runny nose/stuffy nose or nasal congestion *

Decrease or loss of smell or taste *

Nausea, vomiting, diarrhea, abdominal pain *

Not feeling well, extreme tiredness, sore muscles *

Have you travelled outside of Canada in the past 14 days? *

Have you had close contact with a confirmed or probable case of COVID-19? *

Name *

First

Last

Phone

Contact Info