MYC COVID FORM

To ensure the safety of our staff and customers as well as to comply with all regulations we ask you to please fill out your information and answer the questions below.






    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

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

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

    4. I am following the Covid-19 guildelines and regulations as outlined by the Goverment and Provincial Law?

    Results of Screening Questions:
    • If the individual answers NO to all questions from 1 through 3, they have passed and can enter the workplace.
    • If the individual answers YES to any questions from 1 through 3, they have not passed and should be advised that they should not enter the workplace (including any outdoor, or partially outdoor, workplaces). They should go home to self-isolate immediately and contact their health care provider or Telehealth Ontario (1 866-797-0000)to find out if they need a COVID-19 test.