Covid Form

Victory Ford | Covid Form

Symptom Screening Form

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?
YesNo
Difficulty breathing or shortness of breath?
YesNo
Cough?
YesNo
Sore throat or trouble swallowing
YesNo
Runny nose/stuffy nose or nasal congestion?
YesNo
Decrease or loss of smell or taste?
YesNo
Nausea, vomiting, diarrhea, abdominal pain?
YesNo
Not feeling well, extreme tiredness, sore muscles?
YesNo
Have you travelled outside of Canada in the past 14 days?
YesNo
Have you had close contact with a confirmed or probable case of COVID-19?
YesNo
If you have answered yes to any of the above questions you are not to enter the work place. Please self-isolate and contact your health care provider or Telehealth Ontario (1 866-797-0000) to find out if you need a COVID-19 test.