EMPLOYEE COVID-19 SCREENING

Please fill out the following form prior to entering any Community Living Kincardine and District building.

First Name

Last Name

Are you fully Vaccinated (2 or more doses)

Yes

Are you currently experiencing any of these issues? Call 911 if you are. Severe difficulty breathing (struggling for each breath, can only speak in single words) Severe chest pain (constant tightness or crushing sensation) Feeling confused or unsure of where you are Losing consciousness

Yes

Are you suffering from any of the following symptoms not related to allergies or other diagnosed medical condition:

Fever and/or chills

Cough or barking cough (croup)

Shortness of Breath

Decrease or loss of taste or smell

Muscle aches/joint pain

Extreme tiredness

Sore throat

Runny or stuffy/congested nose

Headache

Nausea, vomiting, diarrhea

None of the above

In the last 10 days, has someone you live with: been sick with symptoms associated with COVID-19? and/or tested positive for COVID-19 (on a rapid antigen/home-based test or PCR test)?

Yes

In the last 14 days, have you travelled outside of Canada?

Yes

*NOTE: if you have symptoms, live with someone experiencing symptoms or you/member of your household have tested positive, the "SUBMIT" button will disappear and you will NOT BE PERMITTED onsite at any CLKD location. Please contact your supervisor or the office at 519-396-9434.

I declare that the info I’ve provided is accurate & complete

Initials

Thanks for submitting! You have PASSED the screening.