The following questions are used to screen for COVID-19 before entry into a workplace (business or organization) as per Ontario Regulation 364/20.

If you answer YES to any of these questions, go home/stay home & self-isolate. Call Telehealth or your health care provider, to find out if you need a test.

If you answer NO to all of these questions, you have passed and can enter a Kennedy Contracting Inc., site or Kennedy Contracting Inc., and its screened employees can enter your home for essential work.

If you have an existing health condition that gives you the symptoms you should not answer YES, unless the symptom is new, different or getting worse. Look for changes from your normal symptoms.

Households being entered for essential work must provide 1 form for the household, Organizations/Employees must provide individual forms.

Name

First Name

Last Name

Email

Date

MM

DD

YYYY

Have you travelled outside of Canada in the last 14 days?

YES

NO

Have you been in contact with someone that has a probable or confirmed case of COVID-19 in the last 14 days?

YES

NO

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

YES

NO

Do you have any of the following symptoms?

Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher Cough or barking cough (croup) - Continuous, more than usual, making a whistling noise when breathing, not related to other known causes or conditions (for example, asthma, post-infectious reactive airways, COPD) Shortness of breath - Out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma) Decrease or loss of smell or taste - Not related to other known causes or conditions (for example, allergies, neurological disorders) Sore throat - Not related to other known causes or conditions (for example, seasonal allergies, acid reflux) Difficulty swallowing - Painful swallowing, not related to other known causes or conditions Pink eye - Conjunctivitis, not related to other known causes or conditions (for example, reoccurring styes) Runny or stuffy/congested nose - Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather) Headache that’s unusual or long lasting - Not related to other known causes or conditions (for example, tension-type headaches, chronic migraines) Digestive issues like nausea/vomiting, diarrhea, stomach pain - Not related to other known causes or conditions (for example, irritable bowel syndrome, menstrual cramps) Muscle aches that are unusual or long lasting - Not related to other known causes or conditions (for example, a sudden injury, fibromyalgia) Extreme tiredness that is unusual - Fatigue, lack of energy, not related to other known causes or conditions (for example, depression, insomnia, thyroid dysfunction) Falling down often - For older people

YES

NO

For further information please visit Ontario’s COVID-19 website.

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