COVID-19 Screening Questionnaire

    All persons entering Ontario One Call worksites must complete and submit the checklist below prior to entering the building.

    Your Name

    Your Company

    Contact Phone Number

    1. Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.

    Fever or chills
    YesNo

    Difficulty breathing or shortness of breath
    YesNo

    Cough
    YesNo

    Sore throat, trouble swallowing
    YesNo

    Runny nose/stuffy nose or nasal congestion
    YesNo

    Decrease or loss of smell or taste
    YesNo

    Nausea, vomiting, diarrhea, abdominal pain
    YesNo

    Not feeling well, extreme tiredness, sore muscles
    YesNo

    2. Have you travelled outside of Canada in the past 14 days?

    YesNo

    3. Have you had close contact with a confirmed or probable case of COVID-19?

    YesNo

    If you answered No to all of the questions listed above, you may enter the building.

    If you answered Yes to any of the questions listed above you MAY NOT ENTER the building. Go home to self-isolate immediately and contact your health care provider or Telehealth Ontario (1 866-797-0000) to find out if you need a COVID-19 test.