COVID-19 Self Screening


You must answer “NO” to all the questions in this questionnaire in order to come to your designated worksite. If you answer “YES” to any of the questions, you must self-isolate until you receive further instruction from corresponding health authorities AND notify your supervisor, manager, or HR representative regarding your absence.

Question # Question Answer

Are you experiencing any of the following?

  • Severe difficulty breathing
  • Severe chest pain
  • Having a very hard time waking up
  • Feeling confused
  • Losing consciousness


Are you experiencing any of the following?

  • Mild to moderate shortness of breath
  • Inability to lie down because of difficulty breathing
  • Chronic health conditions that you are having difficulty managing because of difficulty breathing

Are you experiencing any of the following?

  • Fever
  • Cough
  • Sore Throat
  • Runny nose
  • Headache

Have you traveled to any countries outside of Canada (including the United States) within the last 14 days?

Travel includes passing through an airport outside of Canada.


Within the last 14 days did you provide care or have close contact with a symptomatic person known or suspected to have COVID-19?

A close contact is defined as a person who:

  • Provided care for the individual without consistent or appropriate personal protective equipment; or
  • Lived with or otherwise had close prolonged contact (within 2 meters) with the person while they were infectious; or
  • Had direct contact with infectious bodily fluids of a person (e.g. coughed or sneezed on) while not wearing recommended personal protective equipment.

Have you had close contact with a person who traveled outside of Canada in the last 14 days who have become ill (fever, cough, sore throat, runny nose or headache)?


Rev. 01.0 August 2020

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Signature Certificate
Document name: COVID-19 Self Screening
lock iconUnique Document ID: 8bc7577a19c432b6b05b7bb076479fdb1d87dddf
Timestamp Audit
September 22, 2020 8:07 pm GMTCOVID-19 Self Screening Uploaded by Covid Self Screening - IP