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. 1 Name & Department2 Symptoms3 Travel/Contact Name* First Last Home DepartmentWhat 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/EndoscopyOtherContractorsVendors Are you experiencing any of the following symptoms?*YesNo Fever New onset of cough Worsening chronic cough Shortness of breath Difficulty breathing Sore throat Difficulty swallowing Decrease or loss of sense or smell or taste Chills Headaches Unexplained fatigue/malaise/muscle aches (myalgias) Nausea/vomiting, diarrhea, abdominal pain Pink eye (conjunctivitis) Runny nose/nasal congestion without other known cause Have you travelled outside of Canada in the past 14 days?*YesNoHave 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?*YesNoHave you had a positive COVID-19 test within the past 14 days?*YesNoNameThis field is for validation purposes and should be left unchanged.