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Guest Health Questionnaire
Staff Daily Health Check
Please fill out the following health questionnaire to confirm your health at the start of your shift.
If you answered yes to any of these questions
: please return home and self-isolate. Visit OttawaPublicHealth.ca/COVIDCentre for more information about getting tested.
Full Name
Date
Fever/Chills
Yes
No
Cough
Yes
No
Loss of taste or smell
Yes
No
Initials
Difficulty breathing/ shortness of breath
Yes
No
Runny nose (unrelated to allergies)
Yes
No
Sore throat or difficulty swallowing
Yes
No
Not feeling well, headache, unexplained tiredness and muscle aches
Yes
No
Nausea, vomiting, diarrhea, abdominal pain
Yes
No
In the last 14days, have you had close physical contact with a person who was sick with a respiratory illness (had a new or worsening cough, fever or difficulty breathing)?
Yes
No
In the last 14days, have you had close physical contact with a person who has returned from travel outside of Canada in the last 14days?
Yes
No
In the last 14days, have you had close physical contact with a person who was a confirmed or probable case of COVID-19?
Yes
No
In the last 14days, have you travelled outside of Canada?
Yes
No
Submit
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