Staff COVID-19 Screening form

Staff COVID-19 Screening Form
CCS Staff – Please answer the following questions. If you answer yes to any one of them you should not go into work today. Please contact your Director at 613-225-9678 to discuss any further action

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Staff COVID-19 Screening Form

Your name

Your email addressa valid email

1) What is your temperature today?

If you have not been fully vaccinated please be screened at the door before entering the building. Do not fill out this form.

2) Do you or anyone in your household have any "one" of the following new or worsening symptoms?Symptoms should not be chronic or related to other know causes or conditions.

Fever and/or chills (temperature of 37.8° C/100.0°F or higher)Cough or barking cough (croup) - continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causes or conditions they already have.Shortness of breath - Out of breath, unable to breath deeply (not related to asthma or other known causes or conditions they already have)Decrease or loss of smell or taste - not related to seasonal allergies, neurological disorders, or other known causes or conditions they already haveNone of the above

3) Do you or anyone in your household have any "two" of the following new or worstening symptoms?Symptoms should not be chronic or related to other know causes or conditions.

Sore throatHeadacheExtreme fatigue - unusual fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction or other known causes or conditions you already have) Runny nose/nasal congestionMuscle aches/joint pain - unexplained, unusual, or long lasting (not related to sudden injury, fibromyalgia, or other known causes or conditions).Nausea, vomiting, and/or diarrhea - not related to irritable bowel syndrome, anxiety, menstrual cramps, or other know causes or conditions you already have.None of the above

According to the Ministry of Health, if you answered yes to questions 2 and/or 3 for you or anyone in your household, it is highly likely that you/they have a COVID-19 infection.

•You must self-isolate immediately:

For at least 5 days from your symptom onset and until your symptoms have been improving for 24 hours (or 48hours if gastrointestinal symptoms) whichever is longer in duration if you are:

1. 12 years of age or older AND fully vaccinated.

2. 11 years old or younger, regardless of your vaccination status

For 10 days from your symptom onset if you are:

1. 12 years of age or older AND either partially vaccinated or unvaccinated.

2. Immune compromised, regardless of your age

•All of your household members (regardless of their vaccination status) must self-isolate while you are self-isolating.

•Most individuals do not need a COVID-19 test. If you are in the eligible individual list, get PCR test, rapid molecular test or rapid antigen tests (if you have access). If testing is not available, you must fulfill the self-isolation.

•If your symptoms worsen, seek advice from Telehealth (1-866-797-0000) or your health care provider.

•Notify your workplace.

**Please note: If you are exhibiting only one of the following new symptoms:

runny/stuffy nose,

sore throat,

Conjunctivitis (pink eye)

Headache

Extreme tiredness, lack of energy

Muscle aches and pains

GI symptoms (i.e. vomiting or diarrhea)

It is less likely that you have COVID-19 infection.
Your must self-isolate until symptoms are improving, without the use of fever reducing medication, for at least 24 hours (48 hours for gastrointestinal symptoms).

Your household members do not need to self-isolate.

4) In the last 14 days have you travelled outside of Canada and have been advised to quarantine as per the federal quarantine requirements?

YesNo

5) In the last 5 days have you or anyone in your household been identified as a close contact of someone who is confirmed as having COVID-19 by your local health unit (or from the COVID Alert app if they have their own phone)?

YesNo

6) Has a doctor, health care provider, or public health unit told you that you or anyone in the household should be isolating (staying at home)?

YesNo

7) In the last 5 days, has anyone in your household tested positive on a rapid antigen test or a home-based self-testing kit?If you have since tested negative on a lab-based PCR test, select "No"

YesNo

Did you answer yes to any one of the above questions?If you answered yes you cannot attend work today. See below what you will need to do. If you answered No to all the questions, you can go to work today.

YesNo

Next Steps:

Do not come to work. Contact the director (613-225-9678) to let her know about your symptoms
Follow your local public health unit guidance

Ottawa Public Health #: 613-580-6744

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