COVID-19 WORKPLACE SCREENING

All Regional employees must complete a COVID-19 Screening at the beginning of each workday
or shift. This screening should be completed BEFORE entering any Regional building or vehicle.

This form is to be completed by staff who do not have the means or cannot access the COVID-19 Online
Screening at myportal.york.ca/screening

Name: (First, Last):Keira hennessy

Department: Community and Health Services - Public Health

Date & Time of completion: 12:51 April 12, 2021

Screening Questions
Will you be using a Region vehicle, entering a Regional facility or visiting any other location on
Region business? If yes, state address or indicate ‘vehicle’: 17250 Yonge St. Yes
No

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.
Fever or chills No
Cough No
Runny nose/stuffy notes or nasal congestion No
Nausea, vomiting, diarrhea, abdominal pain No
Difficulty breaking or shortness of breath No
Sore throat, trouble swallowing No
Decrease or loss of smell or taste No
Not feeling well, extreme tiredness, sore muscles No

Contact Questions
Have you travelled outside of Canada in the past 14 days? No
Have you had close contact with a probable or confirmed case of COVID-19?
(without adhering to IPAC practices and not wearing PPE) No

If you answered YES to any of the above symptoms or exposures (travel, close contact with a case), do not
report to work today.
• Do not report to work and contact your manager or supervisor and HR Abilities Management Specialist as soon as possible
• Seek assessment at a COVID-19 Assessment Centre
• Self-isolate for up to 14 days; any members of your household or people you have had close contact with from
48 hours before symptoms started should be notified and should also self-isolate until you receive your test
results
The information collected through this screening is collected under the authority of the Occupational Health and Safety Act, R.S.O.
1990, c. O.1 and is collected, used and disclosed in accordance with the Municipal Freedom of Information and Protection of Privacy
Act, R.S.O. 1990, c. M.
56. If you have questions about the collection of this information speak with your Supervisor.

Stay safe. Stay informed.

york.ca/covid19
116 Last Updated Nov 4, 2020 – edocs #11872814