Covid-19 Self Check

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This form must be filled-up EVERY DAY no earlier than 2 to 4 hours BEFORE the beginning of your shift.

Job site entry will not be allowed if you have not filled this form

 

Este formaulario debe ser llenado TODOS los dias, no antes de 2 a 4 horas del comienzo de tu jornada de trabajo.

NO se permite ingresar al lugar de trabajo sin llenar este formulario

 

 

*Required information.

Are you experiencing any of the following:

 

  • Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)
  • Severe chest pain
  • Having a very hard time waking up
  • Feeling confused
  • Losing consciousness
*

 

Are you experiencing any of the following:

  • Mild to moderate shortness of breath
  • Inability to lie down because of difficulty breathing

  • Chronic health conditions that you are having difficulty managing because of difficulty breathing

*

 

Are you experiencing cold, flu or COVID-19-like symptoms, even mild ones?

Symptoms include: Fever*, chills, cough or worsening of chronic cough, shortness of breath, sore throat, runny nose, loss of sense of smell or taste, headache, fatigue, diarrhea, loss of appetite, nausea and vomiting, muscle aches.

While less common, symptoms can also include: stuffy nose, conjunctivitis (pink eye), dizziness, confusion, abdominal pain, skin rashes or discoloration of fingers or toes.

Fever: Average normal body temperature taken orally is about 37°C. For more on normal body temperature and fevers, see HealthLinkBC's information for children age 11 and younger

and for people age 12 and older .

 

*

 

Have you travelled to any countries outside Canada (including the United States) within the last 14 days?

 

*

 

Did you provide care or have close contact with a person with confirmed COVID-19?

Note: This means you would have been contacted by your health authority’s public health team.

 

*

 

Do you believe you have been in recent contact with someone who tested possitive for Covid-19?

 

*

 

Did you answer any of these questions "Yes"

 

*

 

If you answered ANY of these questions as "Yes" please DO NOT come to the job site at all and notify your manager immediately as well as take the necessary precautions of self-isolation and contact your doctor.

 

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