Enterprise

Health
Screening
Form
Updated 12/10/2020

Health screening is mandatory for all TD colleagues in Canada and the U.S. (including
contractors and contingent workers) before you leave home to enter a TD location or another
location on TD business. This includes all colleagues required and approved to work from a TD
location or to meet with customers/clients/vendors.

Instructions:

1. If you choose not to complete the health screening via the TD BoardingPass app, you
must complete the self-assessment using the following health screening questions.
2. If you pass, please proceed to your work location and send your People Manager an
email or text confirming you have completed and passed the screening.
3. Going to a TD location?
Colleagues are required to bring a printed copy of the completed form to show either a
People Manager or on-site health screening coordinator/delegate upon arrival to work.
Please remember to print blank copies of the form in advance.

Anupam Dave
Name: ____________________________

05/10/2021
Date: _____________________________

People with COVID-19 have had a wide range of symptoms reported – ranging from mild
symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. By
answering these questions, you are acknowledging and agreeing that you understand the
questions and have answered each one accurately and truthfully.

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 1. Are you experiencing any of the following new or worsening symptoms even if
you believe they are related to a chronic or pre-existing condition i.e. YES / NO
allergies? Please review the COVID-19 symptom list carefully as changes may be ✔
made from time to time.
Cold or flu symptoms
Fever
Cough
Shortness of breath
Body aches
Sore throat
Diarrhea
Conjunctivitis (pink eye)
Runny nose
Nasal congestion
Nausea or vomiting
Chills
Headache
Severe fatigue
A new loss of taste or smell

YES / NO
2. In the last 14 days, have you been diagnosed with COVID-19 or are you
awaiting the results of a COVID-19 test? ✔

3. In the last 14 days, have you been told to self-isolate or self-quarantine by YES / NO
a medical practitioner, hospital or health agency? ✔

For the next two questions we’ll be defining close contact as

less than 2 metres or 6 feet apart for 10 minutes.
4. In the last 14 days, have you or someone you’ve been in close contact YES / NO
with returned from a cruise or any other travel that now requires you to
✔
self-isolate or self-quarantine?
5. In the last 14 days, have you been in close contact with anyone who is YES / NO
experiencing COVID-19 symptoms, who has been diagnosed with
COVID-19, or who is in self-isolation due to having contact with someone ✔
diagnosed with COVID-19?
If you live in the City of Miami, please move to question 6.
If you do not live in the City of Miami, please move to question 7.
Note: Temperature thresholds will be updated as needed based on local requirements.
YES / NO
6. For the City of Miami ONLY: Is your temperature above 99.5 degrees
Fahrenheit or 37.5 degrees Celsius?
Please move to end of questionnaire.

7. Is your temperature above 100 degrees Fahrenheit or 37.8 degrees YES / NO

Celsius? ✔

If you answer Yes to any of these questions:

• Please do not go to your workplace or another location on TD business, or leave work immediately,
and speak with your People Manager.
• Prior to seeking treatment, alert your healthcare provider or occupational health clinic if you think you
may have COVID-19.
• Tell your healthcare provider if you have been exposed to someone with the virus and have
signs/symptoms of infection, as well as about any recent travel to areas where COVID-19 has spread.
• If you are having trouble breathing, or have any other concerning symptoms, call 911 for immediate
help.

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