COVID-19 Perimeter Screening for Staff/Physicians This Self Screening tool is for use by Employees and Physicians Only. All patients and visitors must go through in-person screening at the designated entrances of the hospital. 1Name & Department2Covid Vaccination Confirmation3Symptoms4Travel/Contact Name* First Last HiddenHome Department What Department are you Working in Today?*AdministrationAdult Day Centre/Supportive HousingAmbulatory Care/Emergency SMGHDiabetes EducationDiagnostic ImagingDietary/Housekeeping FCHSDietary/Housekeeping SMGHFinanceHealth RecordsHome and Community CareHuman ResourcesInformation TechnologyLaboratoryMaintenanceMaterials ManagementMDRDNursing FCHSNursing Administration FCHSNursing Administration SMGHOne South/ICU/RESPOR/Same Day CarePharmacyPhysician SMGHPhysician FCHSRegistrationRehabilitation FCHSRehabilitation SMGHTenantTwo South/EndoscopyOtherContractorsVendorsWhat Site are you Working at Today?*FourCountiesStrathroy Have you received two doses of Covid vaccine?* Yes No Decline to answer Have you received your second dose more than 14 days ago?* Yes No Have you completed your rapid antigen test?* Negative result Positive Result Not tested Are you experiencing any of the following symptoms?* Yes No Fever New or worsening cough (not related to asthma, post-infectious airways or other known cause) Shortness of breath (not related to asthma or other known condition) Decrease or loss of smell or taste (not related to allergies or neurological disorders or other known cause) Fatigue, lethargy or malaise (unusual tiredness not related to depression, insomnia, thyroid dysfunction or other known cause) Muscle aches and pain (not related to covid vaccine in the last 48 hours or other known conditions) If under the age of 18 Nausea, vomiting or diarrhea Have you travelled outside of Canada in the past 14 days?* Yes No Has it been more than 14 days since your second dose? Yes No HiddenHave you had a covid test since your return to Canada? Yes No Have you had close contact (without the use of personal protective equipment) with a confirmed or probable case of COVID-19 in the past 14 days?* Yes No HiddenHave you received your 2nd dose more than 14 days ago? Yes No Has it been more than 14 days since your second dose? Yes No Have you had a positive COVID-19 test within the past 10 days?* Yes No NameThis field is for validation purposes and should be left unchanged.