COVID-19 Daily Screening September 2021

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All employees and visitors entering the premises MUST complete this form PRIOR TO or IMMEDIATELY upon entering building.

For individuals who are 18 years of age and older:
Workplace Site*
Name*
First Last
Date*
DD slash MM slash YYYY

Please read the following statement and answer YES or NO below:

1. Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions.

Fever and/or chills: Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher;

Cough or barking cough: Not related to asthma, post-infectious reactive (croup) airways, COPD, or other known causes or conditions you already have;

Shortness of breath: Not related to asthma or other known causes or conditions you already have;

Decrease or loss of smell or taste: Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have;

(For adults 18 years or older) Fatigue, lethargy, malaise and/or myalgias (muscle aches and pains): Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have.) If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select "No".;

(For children less than 18 years) Nausea, vomiting and/or diarrhea: Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have.
I have read the statement above and my answer is:*

2. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?*
3. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?*
This can be because of an outbreak or contact tracing.
4. In the last 10 days, have you been identified as a "close contact" of someone who currently has COVID-19?*
If public health has advised you that you do not need to self-isolate (e.g. you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared), select "No".
5. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?*
If you have already gone for a test and got a negative result, select "No". If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No".
6. In the last 10 days, have you tested positive on a rapid antigen test or a home based self-testing kit?*
If you have since tested negative on a lab-based PCR test, select "No".
7. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?*
If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select "No". If you are fully immunized or have tested positive for COVID-19 in the last 90 days and have since been cleared, select "No".
Results of Screening Questions:

If you answered "NO" to all questions 1 through 7 - you can enter the workplace.

If you answered "YES" to any questions from 1 through 7, you cannot enter the workplace (including any outdoor or partially outdoor workplace).

You must inform your employer (manager/supervisor) of this result and go home or stay home to self-isolate immediately and contact your health care provider or Telehealth Ontario (1-866-797-0000) to get advice or an assessment including if you need a COVID-19 test. Contact and inform your supervisor or manager at the earliest opportunity for further direction.

If you answered "YES" to question 7, you must stay home, along with the rest of the household, until the sick individual gets a negative COVID-19 test result, is cleared by their local public health unit, or is diagnosed with another illness.

If any of the answers to these screening questions change during the day, you must inform your supervisor or manager of the change and go home to self-isolate immediately. Contact your health care provider or Telehealth Ontario as above.

VISITORS

If you answered "YES" to any questions from 1 through 7 you CANNOT enter this workplace. You should go home to self-isolate immediately and call your health care provider or call Telehealth Ontario (1-866-797-0000) to find out if you need a COVID-19 test.

Domclean COVID-19 Response

Domclean Limited is constantly reviewing and adapting our policies and procedures to ensure the highest level of protection on the health and well-being of our employees, clients, and the public.

We acted in the very early stages to procure additional PPE, disinfectants and hand sanitizer and new equipment technologies as well as a zero policy for illness and strict social distancing requirements. Members of our senior management team formed a task force to ensure that we are following best practices for infection control, continue to maintain adequate resources and adjust our operations as necessary.

Clients

Domclean Limited Operations teams are working closely with each client to tailor our services to your individual needs. We have provided additional cleaning supplies, PPE, equipment and adjusted staffing levels and specifications. Domclean Limited will continue to co-ordinate all aspects of this ever evolving situation with clients. Please contact us if you have any questions or concerns.

Employees

The Health & Safety of all employees has always been paramount to the management of Domclean Limited. We are providing regular updates as the situation changes and ample PPE. Remember that we have implemented a zero policy for illness and you must contact your supervisor immediately if you are feeling unwell. Please contact your immediate supervisor if you have any questions or concerns.