Index - Online Staff/Physician/Volunteer Screening Tool

Online Staff/Physician/Volunteer Screening Tool

I commit to :

An accurate COVID-19 self assessment prior to and during each shift and work day
Reporting to Occupational Health & Safety if answering YES to any screening questions or experiencing symptoms during my work
Practicing excellence in social distancing, PPE utilization and all other Infection Prevention and Control measures
Having my ID Badge visible and with me at all times during my work
Change from street clothes into scrubs/uniform & wear street clothes to leave (applicable to staff who wear uniform/scrubs)

YES *

Have you been fully vaccinated (14 days since dose #2)? *

Yes No

Do you have an approved exemption from William Osler? *

Yes No

Have you completed and submitted your regularly scheduled rapid antigen test? (If you have not submitted your test, please submit here) *

Yes No

Was your result negative? *

Yes No

My COVID -19 self assessment includes honestly answering the following questions:

1. Do you have any of the following symptoms: *

Feverish

Yes

Chills

Yes

New/worsening cough

Yes

Difficulty breathing or swallowing

Yes

Shortness of breath

Yes

Significant headache

Yes

Sore throat

Yes

Body aches

Yes None of these symptoms

New joint pain

Yes

Decreased sense of taste/smell

Yes

Unexplained fatigue

Yes

Diarrhea, Nausea, Vomiting

Yes

2. Have you had contact with a COVID-19+ person without use of appropriate PPE? *

Q3. Have you or a household member traveled internationally in the past 14 days? *

Q4. Is a household member OR a person in the community (e.g. friend or family relative), with whom you had close physical contact with, currently being investigated for COVID-19 and/or has influenza like illness (fever, body aches) or any Covid-19 like symptoms such as; (cough, shortness of breath or sore throat)? *

Q5. Have you had close physical contact with a household member OR a person in the community (e.g. friend or family relative) who has had an exposure to a suspect or confirmed COVID-19 person? *

NO for all (Q2-Q5)

YES to any (Q2-Q5) and been cleared to return to work by OHS

YES to any (Q2-Q5) and NOT been cleared to return to work by OHS

Information Services
William Osler Health System