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!

Date *

Year

Month

Day

Name (First and Last) *

Have you been in close contact with someone who has tested positive or a probable case of COVID-19 in the past 14 days? *

Yes

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

Yes

Do you have any TWO of the following symptoms? *

Yes

Symptoms

I agree to adhere to the COVID-19 PPE requirements while visiting the Municipality of Dutton Dunwich's Facilities* *

I agree

By checking this box I confirm that I have read, understood and answered no to all of the questions above. *

I agree

Dutton Dunwich

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COVID 19 Employee Screening Form

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

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