Covid 19 Screening Questions
d066 Covid-19
Name
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Name
First
First
Middle
Middle
Last
Last
Current Date
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Date
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Gender
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Male
Female
Other
Gender
Phone
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Email
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1.
Do any of the following apply to you? • I am fully vaccinated* against COVID-19 (it has been 14 days or more since your final dose of either a two-dose or a one-dose vaccine series) • I have tested positive for COVID-19 in the last 90 days (and since been cleared cleared by the local public health unit) IF YES, SKIP QUESTIONS 7-10
2.
Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions. The symptoms listed here are the symptoms most commonly associated with COVID19. If you have these symptoms, you should isolate and seek testing. Please note that rapid antigen testing is not to be used for those with symptoms of COVID-19 or for contacts of known COVID-19 cases
A person is fully vaccinated against COVID-19 if, (a) they have received, (i) the full series of a COVID-19 vaccine authorized by Health Canada, or any combination of such vaccines, (ii) one or two doses of a COVID-19 vaccine not authorized by Health Canada, followed by one dose of a COVID-19 mRNA vaccine authorized by Health Canada, or (iii) three doses of a COVID-19 vaccine not authorized by Health Canada; and (b) they received their final dose of the COVID-19 vaccine at least 14 days before seeking access to the premises.
Do you have any of the following symptoms?
Fever and/ or chills
yes
no
Cough or barking cough
yes
no
Shortnes of breath
yes
no
Decrease or loss of smell or taste
yes
no
Fatigue, lethargy, muscle aches, joint pain (for adults > 18 years old)
yes
no
Nausea, vomiting, and/or diarrhea (for children < 18 years old)
yes
no
3. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?
yes
no
4. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing
yes
no
5. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19? If public health has advised you that you do not need to self-isolate, select “No.”
yes
no
6. In the last 10 days, have you tested positive on a rapid antigen test or a homebased self-testing kit?
yes
no
7. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?
yes
no
8. In the last 14 days, has someone in your household (someone you live with) travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?
yes
no
9. In the last 10 days, has someone in your household (someone you live with) been identified as a ”close contact” of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self-isolate?
yes
no
10. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?
yes
no
Adults: (≥18 years old): fever and/or chills; cough or barking cough; shortness of breath; decrease or loss of taste or smell; tiredness; muscle aches. If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is only experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”
yes
no
Results of Screening Questions: • If the patron answered NO to all questions from 2 through 10, they can enter the business or organization. In the business or organization, the patron must continue to follow all public health measures, including masking, maintaining physical distance and hand hygiene, where applicable. • If the patron answered YES to any questions from 2 through 10, they should not be permitted to enter the business or organization (including any outdoor or partially outdoor business or facility). They should be advised to go home to self-isolate immediately and contact their health care provider or Telehealth Ontario (1-866-797- 0000) to get advice or an assessment, including if they need a COVID-19 test. • If the patron answered YES to question 10, they must be advised to stay home, along with the rest of the household, until the sick individual gets a negative COVID-19 result on a valid PCR test (e.g., lab-based PCR or a rapid molecular test, such as ID Now), is cleared by their local public health unit, or is diagnosed with another illness. Rapid antigen testing cannot not to be used test those with symptoms of COVID-19 or for contacts of known COVID-19 cases. • If any of the answers to these screening questions change during the day, this screening result is no longer valid and the patron may need to screen again, wherever necessary. • Any record created as part of patron screening may only be disclosed as required by law.
If you are human, leave this field blank.
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