Test1

Each employee/dentist at the office must complete this form upon return to work.

Name:

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Field is required!

Signature:

Date:

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Field is required!

Risk Assessment Screening Questions

Do you have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre­existing conditions: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose?

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Field is required!

Have you returned to Canada from outside the country (including USA) in the past 14 days?

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Field is required!

In the past 14 days, at work or elsewhere, while not wearing appropriate personal protective equipment:

Did you have close contact* with someone who has a probable** or confirmed case of COVID­19?

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Field is required!

Did you have close contact* with a person who had acute respiratory illness who returned from travel outside of Canada in the 14 days before they became sick?

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Field is required!

Did you have close contact* with a person who had acute respiratory illness that started within 14 days of their close contact* to someone with a probable** or confirmed case of COVID­19?

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Field is required!

Did you have a laboratory exposure to biological material (i.e. primary clinical specimens, virus culture isolates) known to contain COVID­19?

Field is required!
Field is required!

If you answer “NO” to all of the above, you can proceed to work. If you develop symptoms, please complete a new questionnaire.

If you answer “YES” to any of the above, you are not permitted to attend work at this time and you must self­isolate and contact a medical office to determine if you require COVID­19 testing.

*Close contact includes providing care, living with or otherwise having close prolonged contact (within 2 meters) while the person was ill, or contact with infectious bodily fluids (e.g. from a cough or sneeze) while not wearing recommended personal protective equipment.

**Probable case is a person with clinical illness who had close contact to a lab­confirmed COVID­19 case, while not wearing appropriate personal protective equipment, OR a person with clinical illness who meets the COVID­19 exposure criteria, AND in whom laboratory diagnosis of COVID­19 is inconclusive. Clinical illness of a probable case is new onset/exacerbation of following symptoms: fever (over 38 degrees Celsius), cough, shortness of breath (SOB)/difficulty breathing, sore throat or runny nose. Exposure criteria for a probable case is a person who, in the 14 days before onset of illness: had any history of travel outside of Canada; OR had close contact with a confirmed or probable case of COVID­19; OR is a close contact of a traveler with acute respiratory illness who returned from outside Canada in the previous 14 days; OR had a laboratory exposure to biological material (e.g. primary clinical specimens, virus culture isolates) known to contain COVID­19.