Current Style: Standard

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 travelled outside of Canada in the last 14 days? *

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

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

In the last 14 days, have you received a COVID Alert exposure notification on your cell? If you already went for a test and got a negative result, select “No.” *

Have you been vaccinated - not mandatory to answer

Do you have any ONE of the following symptoms? *

Symptoms

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

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

I agree to submit this screening form to the Municipality of Dutton Dunwich.*

Municipality of
Dutton Dunwich
199 Currie Road
Dutton, Ontario N0L 1J0
PHONE
(519)-762-2204
FAX
(519)-762-2278
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Office Hours
Monday to Friday,
8:30 am to 4:30 pm
(except statutory holidays)

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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