Daily Screening Tool - KAS Staffing

The Daily Screening Tool must be completed within 2 hours prior to coming to work to ensure staff, essential visitors and contractors are safe to attend the worksite and maintain the health and safety of others.

Contact Info

Date *

Time *

:

Please enter your name *

First Last

Please enter your email address *

Please include your phone number *

Please select your Branch *

COVID-19 Assessment

Are you experiencing any of these issues? Call 911 if you are. *

– Severe difficulty breathing (struggling for each breath, can only speak in single words)

– Severe chest pain (constant tightness or crushing sensation)

– Feeling confused or unsure where you are

– Losing consciousness

Yes
No

Are you currently experiencing any of these symptoms that are new, worsening, and not related to other known causes or conditions you already have? *

– Fever (temperature of 38ºC / 100ºF or higher)

– Chills

– Cough that is new or worsening (continuous, more than usual, not related to other known causes or conditions, for example, COPD)
– Barking cough, making a whistling noise with breathing (croup, not related to other known causes or conditions)

– Shortness of breath (out of breath, unable to breathe deeply, not related to other known causes or conditions, for example, asthma)

– Sore throat (not related to other known causes or conditions, for example, seasonal allergies, acid reflux)

– Difficulty swallowing (painful swallowing, not related to other known causes or conditions)

– Runny nose (not related to other known causes or conditions, for example, seasonal allergies, being outside in cold weather)

– Stuffy or congested nose (not related to other known causes or conditions, for example, seasonal allergies)

– Decreased or loss of taste or smell (not related to other known causes or conditions, for example, seasonal allergies, neurological disorders)

– Pink eye (conjunctivitis, not related to other known causes or conditions, for example, recurring styes)

– Headache that is unusual or long-lasting (not related to other known causes or conditions, for example, tension-type headaches, chronic migraines)

– Digestive issues like nausea/vomiting, diarrhea, stomach pain (not related to other known causes or conditions, for example, irritable bowel syndrome, menstrual cramps)

– Muscle aches that are unusual or long-lasting (not related to other known causes or conditions, for example, a sudden injury, fibromyalgia)

– Extreme tiredness that is unusual (fatigue, lack of energy, not related to other known causes or conditions, for example, depression, insomnia, thyroid dysfunction)

Yes
No

Have you been recently tested for COVID-19 due to symptoms and are waiting for results or have tested positive? *

Yes
No

Has a doctor, health care provider, or a Public Health Unit told you that you should currently be isolating (staying at home)? *

Yes
No

In the last 14 days, have you been in close contact with someone who either: *

– is currently sick with a new cough, fever, difficulty breathing, or other symptoms associated with COVID-19? Or,

– has been recently tested for COVID-19 due to symptoms? Or,

– has a confirmed, or possible case of COVID-19? Or,

– returned from outside of Canada in the last 2 weeks for non-essential travel?

Close physical contact means any of the following:

– Being less than 2 metres away in the same room, workspace, or area without PPE for an extended time

– Living in the same home

Yes
No

Have you travelled outside of Canada in the last 14 days? (This does not include essential workers who cross the Canada-US border regularly.) *

Yes
No

In the past 14 days, have you received a COVID Alert exposure notification on your cell phone? (If you already went for a test and got a negative result, select NO) *

Yes
No

If you answered NO to all of the questions, you are safe to come to the worksite.

If you answered YES to any of the above questions, you are NOT considered safe to come to the worksite.

– Please contact your manager to advise that you have not passed the Daily Screening Tool and will not be coming to work today

– Please stay home and self-isolate to reduce the risk of exposure to your friends, family and colleagues

– Refer to Self-Isolation Procedures

– Follow the directions of Public Health Ontario: https://covid-19.ontario.ca/self-assessment/

Please click Submit. Thank you for taking the time to complete this assessment.