Parklane Self Report of Infectious Illness

Note: At the time of printing, this form had not been submitted.

Introduction

I agree to the above

Please check which one of the following you are reporting

I am unwell and have new symptoms that I would like to report to OH&S.

I've been off sick and would like to determine if I can return. (Return to work assessment form)

Travel

Have you travelled outside of Canada within the last 14 days?

Yes No

COVID-19

Have you:

been in contact with an individual who has tested positive for COVID-19, or
been in contact with a household member with symptoms of COVID-19, or
been contacted by Public Health regarding COVID-19 exposure, or
been notified by a COVID-19 tracing app?

Yes No

Have you been tested for COVID-19?

Yes No

Reason For COVID-19 Test:

COVID-19 Test Result:

Respiratory Symptoms

Select the symptoms you are experiencing (check all that apply).

Fever
New or worsening cough
Sore throat or difficulty swallowing
Shortness of breath

Earliest date of respiratory symptom onset

Gastrointestinal Symptoms

Are you newly experiencing any of the following gastrointestinal symptoms? (Check all that apply)

Vomiting
Diarrhea

Earliest date of gastrointestinal symptom onset

General Symptoms

Are you experiencing any of the following general symptoms that is more than a normal symptom?
i.e. diagnosed seasonal allergies, migraines, etc (check all that apply)

Myalgias or body aches
Runny nose
Chills
Change in taste or smell
Unexplained fatigue or malaise
Severe Headache

Additional COVID-19-related symptoms that have not been listed

Please list your additional COVID-19-related symptoms

Other Situations

Please indicate if any of these other situations apply to you

I have a new Rash or Open Cold Sore
I have Conjunctivitis / Pink Eye

Earliest date of symptom onset

I work in a unit that has been declared to be in an outbreak

Return to Work Assessment

Were you sick with any of the following symptoms or had any of the following requirements? (Select all that apply)

Fever
New or worsening cough
Sore throat or difficulty swallowing
Shortness of breath
Vomiting
Diarrhea
Myalgias or body aches
Runny nose
Severe Headache
Unexplained fatigue or malaise
Decrease or loss of sense of taste or smell

Rash or Open Cold Sores
Conjunctivitis / Pink Eye

Other COVID-19 symptoms not listed

Please list your additional COVID-19-related symptoms

Return to Work Assessment

You indicated you had the following symptom(s):

Are you feeling better AND have you been symptom-free for 24 hours?
Yes No

Were you required to Self-Isolate or Quarantine?
Yes No

What was the reason for Self-Isolation / Quarantine?

Travel
I was in contact with a person who was COVID-19 positive
I had a COVID-19 positive lab test

When did you enter Self-Isolation / Quarantine?

Have you completed the Self-Isolation / Quarantine?
Yes No

Have you been tested for COVID-19?
Yes No

What was the COVID-19 Test Result?

Can you provide documentation of the COVID-19 Test Result? Yes No

Do you work in a unit that has been declared to be in an outbreak?
Yes No

Basic Dialog