COVID Questionnaire

Email Address

Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to existing or other known causes or conditions. IF you have symptoms which are clearly known to be from something other than or were from prior to COVID-19, then select NO (ie. allergies). IF you have symptoms without a known cause, then select YES. If unsure, please select YES.

Fever or chillsNoYes

Difficulty breathing or shortness of breathNoYes

CoughNoYes

Sore throat, trouble swallowingNoYes

Runny nose/stuffy nose or nasal congestionNoYes

Decrease or loss of smell or tasteNoYes

Nausea, vomiting, diarrhea, abdominal painNoYes

Not feeling well, extreme tiredness, sore musclesNoYes

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

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

If answering NO to All Questions Above, then you have passed the screening and can enter Interactive Audio Visual workplace.

Results of Screening Questions:

If you answered YES to any questions above, you have not passed and should be advised that you should not enter the workplace (including any outdoor, or partially outdoor, workplaces). You should go home to self-isolate immediately and contact their health care provider or Telehealth Ontario (1 866-797-0000) to find out if they need a COVID-19 test.

If you answered YES to any of the above, and have no pre-existing condition or explanation for the condition you answered yes to, then you must advise your IAV manager and self-isolate. You can still work from home. If the condition warrants (ie. you should check with health care provider or Telehealth Ontario), you may need to arrange to get a COVID test. In this situation you continue to work from home until you can provide a proof of a negative result from an accredited Covid test facility. This test result, regardless of result, is to be emailed to Carol Ann Smiley or Ruth Lebel once received. IF tested and result is negative, you can then return to the workplace – but not until a negative result is received and communicated to IAV.

I hereby confirm that my answers to the above questions are true, accurate and complete,

I understand and acknowledge that the above questionnaire is not intended to provide medical advice and cannot be relied upon as medical advice.

I undertake to:

(a) Wash my hands frequently, practice physical distancing and follow any other direction of the applicable public health authorities as it may relate to COVID-19 and the workplace;

(b) That Interactive Audio Visual continues to make readily available several COVID-19 preventative measures such as (not limited to) hand sanitizers, disinfectants, supply of face masks and filters, plus clear plastic face shields and other recognized preventative measures throughout the workplace, and I will continue to utilize them daily as appropriate to protect myself and others to help reduce to potential spread of COVID-19;

(c) If required, self-monitor and follow the precautions set out in this questionnaire; and

(d) Retake the above questionnaire if any of the answers provided from the start of the workday have changed during the workday;

I understand that as of September 25, 2020, The Ontario Government amended Regulation 364/20 under the Reopening Ontario (A Response to COVID-19) Act, 2020. As such this form is a provincially mandated requirement and I will comply with said mandate for each day I intend to enter the Interactive Audio Visual Inc. workplace.