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COVID 19 Employee Screening Form

Preserving the health and wellness of our staff is the Municipality of Dutton Dunwich priority. To prevent the spread of COVID-19, and to reduce the potential risk to our staff, we are conducting a simple screening questionnaire that we are asking you to complete at the beginning of each day, and submit in advance of starting work. If at any time, there are changes in your health and/or situation please notify your supervisor immediately.

This checklist is meant to keep you and your colleagues healthy. It is only a basic checklist and not meant to take the place of medical advice, diagnosis or treatment.

NOTE:  If you answered yes to any of these questions DO NOT enter this facility and notify your supervisor immediately. Thank you!

Symptoms
Fever
New onset of cough
Worsening chronic cough
Shortness of breath
Difficulty breathing
Sore throat
Hoarse Voice
Difficulty swallowing
Decrease or loss of sense of taste/smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches
Diarrhea
Abdominal pain
Nausea/vomiting
Pink eye (conjunctivitis)
Runny nose/sneezing without other known cause
Nasal congestion without other known cause
  • Office Hours

  • Monday to Friday,
  • 8:30 am to 4:30 pm
  • (except statutory holidays)