Covid-19

Alberta Workspace Form

Daily Fit for Work or Essential Visitor Screening Questionnaire

We require you to fill out the below questionnaire to assist in determining your fitness to work or visitation during the COVID-19 pandemic to provide a safe environment for staff, physicians, contractors, patients and families.

The information in this questionnaire is collected under the authority of FOIP section 33 (c) and will be used and disclosed solely for the purposes of determining fitness for work or visitation during the COVID-19 pandemic.

Ensure at all times you are following protocols for hand hygiene and also remember to clean your keys, phone, computers and other personal items.

The questionnaire intends to identify new symptoms or worsening of symptoms that are related to allergies, chronic or pre-existing conditions. Those with symptoms related to preexisting conditions or allergies can still go to work or visit.

Name*

First Last

Are you fully vaccinated for Covid-19?

An individual is considered fully vaccinated if it has been more than 2 weeks since they received the last shot of a 2-dose vaccine (for example, Moderna or Pfizer) or a single dose vaccine (J&J).

Yes
No

Do you have any of the following symptoms?

Fever
Cough
Shortness of breath
Difficulty breathing
Sore throat
Runny nose

Have you returned to Canada from outside the country (including USA) in the past 14 days?*

Yes
No

In the past 14 days, at work or elsewhere, while not wearing appropriate personal protective equipment:

Did you have close contact* with someone who has a probable** or confirmed case of COVID-19?*

Yes
No

*Close contact includes providing care, living with or otherwise having close prolonged contact (within 2 meters) while the person was ill, or contact with infectious bodily fluids (e.g. from a cough or sneeze) while not wearing recommended personal protective equipment.

**Probable case is a person with clinical illness who had close contact to a lab-confirmed COVID-19 case, while not wearing appropriate personal protective equipment, OR a person with clinical illness who meets the COVID-19 exposure criteria, AND in whom laboratory diagnosis of COVID-19 is inconclusive. Clinical illness of a probable case is new onset/exacerbation of following symptoms: fever (over 38 degrees Celsius), cough, shortness of breath (SOB)/difficulty breathing, sore throat or runny nose. Exposure criteria for a probable case is a person who, in the 14 days before onset of illness: had any history of travel outside of Canada; OR had close contact with a confirmed or probable case of COVID-19; OR is a close contact of a traveler with acute respiratory illness who returned from outside Canada in the previous 14 days; OR had a laboratory exposure to biological material (e.g. primary clinical specimens, virus culture isolates) known to contain COVID-19.

Did you have close contact* with a person who had acute respiratory illness that started within 14 days of their close contact* to someone with a probable** or confirmed case of COVID-19?*

Yes
No

Did you have close contact* with a person who had acute respiratory illness who returned from travel outside of Canada in the 14 days before they became sick?*

Yes
No

Did you have a laboratory exposure to biological material (i.e. primary clinical specimens, virus culture isolates) known to contain COVID-19?*

Yes
No

If you answer “YES” to any of the above, you are not permitted to attend work or visit at this time and you must self-isolate. For healthcare workers, complete the Healthcare Worker Self-Assessment Tool at , ahs.ca/covid to determine your need for COVID-19 testing. Please inform ALL managers/leads you report to.

If you answer “NO” to all of the above, you can proceed to work or with your visit. If you develop symptoms, please complete a new questionnaire.

Signature*