Complete this form prior to entering CoMotion.
This screening form must be filled out daily before you enter CoMotion. No exceptions.

* If you say Yes to any symptom or question, please DO NOT come into the space.
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Your Name (First & Last) *
Today's Date *
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Mandatory Covid-19 Screening Questions
We are following the Provincial screening tool.

Please note:
This form must be completed each day you will physically be at CoMotion. If you do not complete this form, you cannot physically work at CoMotion or be in the space. All staff, coworkers, visitors, and vendors must complete this form. No exceptions.

If you answer NO to all questions, you are free to work at CoMotion. If you answer YES to any question you cannot work at CoMotion and must contact your health provider, take the online self-assessment and/or contact Telehealth Canada for next steps.
1. 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. *
Yes
No
Fever or chills
Difficulty breathing or shortness of breath
Cough
Sore throat, trouble swallowing
Runny nose/stuffy nose or nasal congestion
Decrease or loss of smell or taste
Nausea, vomiting, diarrhea, abdominal pain
Not feeling well, extreme tiredness, sore muscles
2. In the last 10 days, has a doctor, health care provider, or a public health unit told you that you should be self-isolating? *
3. In the last 10 days, have you been identified as a "close contact" of someone who currently has COVID-19 and/or have you received a government COVID Alert exposure notification? If you are fully vaccinated then answer "No". *
4. In the last 10 days, have you tested positive or are presumed positive with COVID-19? If you have met the requirement that requires you to isolate for 10 days, then answer "No". *
5. In the last 10 days, has someone in your household tested positive or is presumed positive with COVID-19? If you have met the requirement that requires you to isolate for 10 days, then answer "No". *
6. In the past 14 days, have you recently travelled outside of the country, and have not met the government requirements for entry to Canada, including any vaccination, testing, or quarantine requirements in order to return to the office? *
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