Form Builder

COVID-19 Contractor Screening Questionnaire 

March 09, 2021 v5

Please complete this questionnaire once daily before entering a Town work site.

  1. Are you currently experiencing one or more of the symptoms below that are new or worsening?                                                                                           

Symptoms should not be chronic or related to other known causes or conditions. 

For individuals who are 18 years of age and older: 

Do you have one or more of the following symptoms?  Please answer with the Contact Answer Below:

Fever and/or chills

Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Cough or barking cough (croup)

Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have

Shortness of breath

Not related to asthma or other known causes or conditions you already have

Sore throat

Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have

Difficulty swallowing

Painful swallowing not related to other known causes or conditions you already have 

Extreme Tiredness

 

Unusual fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have) 

Decrease or loss of smell or taste

Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

Pink eye

Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)

Runny or stuffy/congested nose

Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have

Headache

Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)

Digestive issues like nausea/vomiting, diarrhea, stomach pain

Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have 

Muscle aches

Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have)

Falling down often

For older people 



Group Exemptions, Quarantine Requirements (link to Canada.ca information)

If you answered YES to any of these questions, DO NOT ENTER THE WORKSITE.  You must contact the Town immediately.   

If you answered “Yes” to question “6.” you must stay home until the sick individual gets a negative COVID-19 test result, is cleared by their local public health unit, or is diagnosed with another illness. 

Completion of this declaration is mandatory. Failure to provide information will prevent you from entering a facility. Please complete your details to confirm you have read and understand the declaration.

Declaration

  1. I acknowledge COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious and that I have an elevated risk of contracting COVID-19 by being around other people in a public setting and I hereby assume the risks with respect to acquiring COVID-19 inherent in participating in work at a Town of Gravenhurst site(s), including the associated risk of death or severe bodily injury that may accompany COVID-19.
  2.  I hereby release and save harmless The Corporation of the Town of Gravenhurst and its employees and representatives from any and all claims and demands associated with my acquiring COVID-19, from working at a Town of Gravenhurst site, due to any cause whatsoever, including negligence, breach of contract, mistakes or errors in judgment. This Release of Liability shall be binding upon my heirs, next of kin, executors, administrators, assigns and representatives
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