Request a Locate

COVID-19 Screening Questionnaire

All persons entering Ontario One Call worksites must complete and submit the checklist below prior to entering the building.

Your Name

Your Company

Contact Phone Number

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.

Fever or chills
YesNo

Difficulty breathing or shortness of breath
YesNo

Cough
YesNo

Sore throat, trouble swallowing
YesNo

Runny nose/stuffy nose or nasal congestion
YesNo

Decrease or loss of smell or taste
YesNo

Nausea, vomiting, diarrhea, abdominal pain
YesNo

Not feeling well, extreme tiredness, sore muscles
YesNo

2. Have you travelled outside of Canada in the past 14 days?

YesNo

3. Have you had close contact with a confirmed or probable case of COVID-19?

YesNo

If you answered No to all of the questions listed above, you may enter the building.

If you answered Yes to any of the questions listed above you MAY NOT ENTER the building. Go home to self-isolate immediately and contact your health care provider or Telehealth Ontario (1 866-797-0000) to find out if you need a COVID-19 test.