Self-Assessment - Topline Facilities Management

Your Name *

Your Email *

Your Tel No *

Location/Service Area *

1. Are you experiencing any of the following symptoms: fever, cough, shortness of breath?

YesNo

2. Have you experienced cold or flu-like symptoms (fever, dry cough, difficulty breathing, and respiratory illness) in the last 14 days?

YesNo

3. Have you experienced any of the following additional symptoms in the last 14 days?

YesNo

Severe difficulty breathing, severe chest pain, feeling confused or unsure where you are, losing consciousness, fever, chills, new or worsening cough, shortness of breath, sore throat, difficulty swallowing, runny nose (not related to allergies), stuffed nose, loss of sense of taste or smell, pink eye, headache, digestive issues, muscle aches, extreme tiredness, falling down often.

4. Have you travelled outside of Canada in the last 14 days?

YesNo

5. Have you been in close contact / live with anyone who has travelled outside of the country and returned in the last 14 days?

YesNo

6. Have you had close contact with a person who is insolation, or cared for someone in isolation, or has a suspected or confirmed case of COVID-19?

YesNo

7. Do you have a temperature above 38 degree Celsius?

YesNo

8. Have you been told to self-isolate by Public Health or a medical professional?

YesNo

NO to all questions – PASS. You may enter the building and proceed as scheduled.

If you answered YES to any of these questions, do not enter the facility go home & self-isolate right away. Call your health care provider, for next steps