Employee COVID-19 Survey - Aim Lock and Safe

*Please complete the following COVID-19 screening questionnaire at the start of each shift.
QUESTION 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.

Click any/all that are new, worsening, and not related to other known causes or medical conditions.
Fever and/or Chills
YES No
(Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher)
Cough or barking cough (croup)
YES NO
Continuous, more than usual, making a whistling noise when breathing, not related to other known causes or conditions (for example, asthma, post-infectious airways, COPD)
Shortness of breath
YES NO
Out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma)
Decrease or loss of smell or taste
YES NO
Not related to other known causes or conditions (for example, allergies, neurological disorders)
Sore throat
YES NO
Not related to other known causes or conditions (for example, seasonal allergies, acid reflux)
Difficulty swallowing
YES NO
Painful swallowing not related to other known causes or conditions
Pink eye
YES NO
Conjunctivitis, not related to other known causes or conditions (for example, reoccurring styes)
Runny or stuffy/congested nose
YES NO
Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather)
Headache that’s unusual or long lasting
YES NO
Not related to other known causes or conditions (for example, tension-type headaches, chromic migraines)
Digestive issues like nausea/vomiting, diarrhea, stomach pain
YES NO
Not related to other known causes or conditions (for example, irritable bowel syndrome, menstrual cramps)
Muscle aches that are unusual or long lasting
YES NO
Not related to other known causes or conditions (for example, a sudden injury, fibromyalgia
Extreme tiredness that is unusual
YES NO
Fatigue, lack of energy, not related to other known causes or conditions (for example, depression, insomnia, thyroid dysfunction)
Falling down often
YES NO
For older people
QUESTION 2: Have you travelled outside of Canada in the last 14 days?
YES NO
QUESTION 3: In the last 14 days, has any public health unit identified you as a close contact of someone who currently has COVID-19?
YES NO
QUESTION 4: Has a doctor, health care provider, or public health unit told you that you should currently be isolating? (Staying at home)?
YES NO
QUESTION 5: In the last 14 days, have you received a COVID alert exposure notification on you cell? (If you already went for a test and got a negative result, select “No”.
YES NO

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