COVID Daily Checkin

To prevent the spread of the virus and reduce the potential risk of exposure to our teams, please complete the following questionnaire prior to entering the office.

First Name *

Last Name *

Location *

House Team *

1. Are you experiencing, or have you experienced in the last 10 days a fever, chills, a sore throat, or a shortness of breath? *

Yes
No

2. Are you experiencing, or have you experienced in the last 10 days unusual fatigue, a loss of your sense of smell, taste or appetite, or any recent nausea, vomiting, diarrhea? *

Yes
No

3. Are you experiencing, or have you experienced in the last 10 days new onset or worsening cough, runny nose, headaches or muscle aches? *

Yes
No

4. In the past 14 days, have you been in close contact with someone who has a confirmed COVID-19 diagnosis? *

Yes
No

5. Are you currently under a Health Authority requirement to self-isolate or quarantine due to possible exposure to COVID -19, or recent international travel (including the United States)? *

Yes
No

Resource information taken from the BC Centre for Disease Control Nov 20, 2020: http://www.bccdc.ca/health-info/diseases-conditions/covid-19/about-covid-19/symptoms

Agreed

By checking this box, I certify that the information provided above is truthful and I further confirm that I have notified my supervisor about my answers to the above questions and that I am fit for duty.