Health Questionnaire

COVID Ops Questionnaire

Date*
Date Format: MM slash DD slash YYYY
Name*
First Last
1. Are you displaying any of the following new or worsening symptoms?*
Fever, Cough, Loss of smell or taste, Difficulty Breathing, Sore throat, Loss of appetite, Extreme fatigue or tiredness, Headache, Body Aches, Nausea or vomiting, Diarrhea
- Yes
- No
2. Have you travelled to any countries outside Canada (including the United States) within the last 14 days?*
- Yes
- No
3. Have you been identified by Public Health as a close contact of someone with COVID-19?*
- Yes
- No
4. Have you been told to isolate by Public Health?*
- Yes
- No
Verification*
I hereby declare that the information provided is true and correct.
- I Agree

If you have checked YES to any questions, stay home, do not report to work, and contact your manager.

If you are displaying symptoms consistent with COVID-19, refer to HealthLink BC at 811.

We share a responsibility for keeping each other safe. Thank you for completing this questionnaire.

If you have any questions, please contact your manager.

*source: WorkSafe BC