COVID-19 Self Screening Questionnaire (DRAFT - Test 2.2)


Please complete the Self-Screening Tool daily before arriving on campus.

 

The results displayed at the end of this questionnaire will need to be viewed by screening personnel. This questionnaire is only meant to be a tool and cannot diagnose you. If you have medical questions or concerns about your personal risk factors, consult a health care provider or the Public Health Sudbury and District.

 

 

NOTE: This self-disclosure questionnaire is confidential and is to be used for screening purposes only. No contact information will be collected or saved. If you any questions about the collection and use of this information please contact Human Resources at hrd@laurentian.ca.

 

 

There are 3 questions in this survey.

Are you currently experiencing any of the following symptoms:

  • fever, 
  • sore throat, 
  • cough,
  • shortness of breath,
  • malaise (fatigue or feeling of being generally unwell),
  • runny nose, and/or
  • other symptoms of COVID-19 including but not limited to: Aches and pains, diarrhoea, conjunctivitis, headache, loss  of taste or smell, a rash on skin, or discolouration of fingers or toes.
Yes
No
Have you been in contact with someone who is sick, has travelled or has had a confirmed case of COVID-19 within the past 14 days?
Yes
No
Have you returned from travel outside of Canada within the past 14 days?
Yes
No