COVID-19 Screening Questionnaire The purpose of the screening process is to assist employers and their employees in safeguarding the health and safety of their workers at the workplace by mitigating the risk of spreading the respiratory illness caused by COVID-19. This document Is a tool for conducting and documenting results of the COVID-19 screening assessment. In order to determine if there is any risk for the employee to be present at the workplace or if the employee poses a risk to the other employees. If there is a positive screening result or if you choose not to participate in the screening, we will not be able to advise you or clear you to return to the workplace until you have been medically clear through another means. We will notify your employer that you were not cleared to enter the workplace and have been advised to seek medical advice. This screening process is not intended to replace testing for COVID-19, nor is it intended to replace advice provided by your family physician or other primary care provider. This screening process is based on the current public health recommendations and requirements for workplaces approved to operate.Name* Email* Do you consent to participate in the screening assessment process?* Yes No Are you or is anyone in your household feeling feverish, had shakes or chills in the last 10 days (above 37.8 degrees Celsius/100.4 Fahrenheit)?* Yes No Are you experiencing any other illness symptoms such as: Vomitting/ Diarrhea, New headaches, Sore throat, Loss of sense of smell and/or taste, Unexplained fatigue, Allergy symptoms* Yes No Do you have a new/recent or worsening cough?* Yes No Have you received an exposure notification from the COVID alert app in the last 14 days?* Yes No Have you been experiencing difficulty breathing?* Yes No Have you traveled outside of Canada within the last 14 days?* Yes No Have you come into contact with a confirmed case of COVID-19 or anyone who has been ordered to self isolate in the last 14 days?* Yes No Have you worked on any other productions in the last 14 days? (Details are only utilized to assist in contact tracing if required)* Yes No Prefer not to say Please list below the production name and the dates worked for contact tracing purposesHave you received a vaccination against COVID-19?* Yes No Prefer not to say How many doses have your received?* 1 2 Do you have a compromised immune system due to an underlying health condition?* Yes No I hereby certify-that the above information is correct to the best of my knowledge. I understand that the accuracy and truthfulness of the information provided is important to the health and safety of the public and the health and safety of my fellow employees and workplace.