COVID-19 Screening - Contractors and Visitors

Required fields are marked with asterisks (*)

COVID-19 SCREENING QUESTIONS

Please complete the following form daily prior to entering the workplace.

The screening tool used is the same tool issued by the Office of the Chief Medical Officer of Health. Please review the originial screening questions for any clarification: COVID-19 Screening Tool for Businesses and Organizations.

Any further questions can be directed to Marcy Warren (mwarren@dryden.ca) or Liz Godin (lgodin@dryden.ca).

Refer to policy HR-HS-54, Preventing COVID-19 in the Workplace for more information.

Visitor Name

Are you fully vaccinated?

Yes

No / Prefer not to disclose

In the last 14 (fourteen) days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?

Yes

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

Do any of the following apply?

You live with someone who is isolating because of a positive COVID-19 test

You live with someone who is isolating because of COVID-19 symptoms

You live with someone who is waiting for COVID-19 test results

None of the above

You have passed the screening. Please proceed to work.

I acknowledge that I passed the screening. If I develop symptoms while at work, I will notify my supervisor.

Visitor Signature

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COVID-19 SCREENING QUESTIONS

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