COVID-19 Screening Tool Diversified Staffing COVID-19 Screening Tool COVID-19 Screening Tool City Select a CityCalgaryEdmontonRed Deer Division Select a DivisionIndustrialOffice Full Name Email Phone Do you have any of the following symptoms or have had any of the symptoms in the past 10 days: fever, and/or cough, or shortness of breath and/or any flu like symptoms? —Please choose an option—YesNo Have you had exposure or close contact with someone who was ill and/or had recently travelled outside of Alberta in the last 10 days? —Please choose an option—YesNo Have you travelled into or out of Alberta in last 14 days? —Please choose an option—YesNo Are you currently working in a hospital, long-term care facility, retirement home or a care facility? —Please choose an option—YesNo Albertans are legally required to isolate for: • 14 days if they are a close contact of someone with COVID-19 or returned from international travel • 10 days from the start of your symptoms (not related to a pre-existing illness or health condition: cough, fever, shortness of breath, runny nose or sore throat) or until they resolve, whichever is longer https://www.alberta.ca/isolation.aspx • If you have any of the other symptoms, stay home and minimize your contact with others until your symptoms resolve. • Monitor your symptoms and call Health Link 811 if you have questions or concerns. Declaration: I declare that I have answered the above questions truthfully and to the best of my knowledge. Date: For more information on the COVID-19, please visit the Alberta Health Services website https://www.alberta.ca/covid19 If you have any concerns about your health, please contact Alberta Health Link at 811. If you have no symptoms or exposure concerns, but have questions about COVID-19 or novel coronavirus, please visit the following resources: • Alberta.ca/COVID19 – Learn about COVID-19 and actions being taken to protect the health of Albertans • AHS COVID-19 Response - Information for Albertans and Health Professionals. • Frequently Asked Questions https://www.canada.ca/coronavirus Δ
