Unit Park - PRE-SCREENING QUESTIONS

Employee Name:

Location you work at?

1. Do you have a fever of have felt hot or feverish anytime in the last 10 days?

YES

NO

2. Do you have any of these symptoms: New or worsening cough? New or worsening shortness of breath? Difficulty breathing? Sore throat or painful swallowing? Runny nose?

YES

NO

3. Have you experienced a recent loss of smell or taste?

YES

NO

4. Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?

YES

NO

5. Have you returned from travel outside of Canada in the last 14 days?

YES

NO

6. Have you returned from travel within Canada from a location known affected with COVID-19 in the last 14 days?

YES

NO

7. Is your workplace considered high risk?

YES

NO

8. Are you over the age of 65?

YES

NO

9. Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?

YES

NO

Supervisor Name:

Phone #

Supervisor Email

Date:

SIGNATURE OF EMPLOYEE:

UNIT PARK EMPLOYEE

PRE-SCREENING QUESTIONS:

THE FORM MUST BE SUBMITTED PRIOR TO START OF SHIFT

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

RISK VULNERABILITY

YES

NO

YES

NO

YES

NO

PRE-SCREENING QUESTIONS form successfully submitted. Thank You!