Re-entry to Workplace Questionnaire

Order Number

Instructions

We require you to fill out the below questionnaire to assist in determining your fitness to return to the work office during the COVID-19 pandemic to provide a safe environment for all staff and clients. The information in this questionnaire is collected and will be used and disclosed solely for the purposes of determining fitness to return to work during the COVID-19 pandemic.

You will be required to resubmit this questionnaire should your conditions change.

Section 1 - Employee Information

First Name *

Last Name *

Email Address *

Ensure the entered e-mail is correct

Department *

Supervisor / Manager *

Date Requested

Sep/10/2024

Expected day (s) in office *

Half-Day Full Day Multiple Days

Section 2 - Questionnaire

1. Are you currently experiencing, or have you experienced any of the following symptoms in the past fourteen (14) days? *

Yes No

1. Are you currently experiencing, or have you experienced any of the following symptoms in the past fourteen (14) days?

Chills

Cough

Fever (100.0F/ 37.8 degrees or greater)

Headaches

Loss of taste / smell

Sore Throat

Shortness of breath or difficulty breathing

Muscle Aches

Nausea, Diarrhea, Vomiting

2. Have you been in contact with anyone suspected of being infected with COVID-19 or who has had symptoms compatible with COVID-19 in the past fourteen (14) days? *

Yes No

3. Does anyone residing in your home, work as a healthcare professional at a public health institution / hospital? *

Yes No

4. Have you visited any public places within the last 14 days that have been identified as possible contact locations for the spread of COVID-19? *

Yes No

Comments

Acceptance of Terms and Conditions

I accept the terms and conditions