Title Page
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DAC Daily COVID Questionnaire
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Employee Name:
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Conducted on
Do you currently have the following symptoms (section 1)
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Chills, fever over 38 ˚C ?
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Recent cough or worsening of a chronic cough?
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Trouble breathing?
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Sudden loss of smell and taste?
Do you currently have the following symptoms (section 2)
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Sore throat?
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Runny nose?
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Nausea and vomiting?
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Headaches?
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Extreme fatigue?
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Diarrhea in the last 12 hours?
You’re legally required to self-isolate for 14 days or as directed by Public Health if you:
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have COVID-19 symptoms and are waiting to be tested and get your test results?
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were at a potential exposure site and Public Health advises that you need to self-isolate while you’re waiting to be tested and for your test results?
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have been tested for COVID-19 and have been told by Public Health that you need to self-isolate while you’re waiting to get your test results?
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have tested positive for COVID-19?
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have been told by Public Health that you’re a close contact of a confirmed COVID-19 case or may have been exposed to COVID-19 and need to self-isolate, even if you don’t have symptoms?
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have travelled from outside Nova Scotia, Prince Edward Island or Newfoundland and Labrador, even if you don't have symptoms (For Leisure)
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are sharing any living spaces with someone who has travelled into Nova Scotia or returning to Nova Scotia from outside Nova Scotia, Prince Edward Island or Newfoundland and Labrador for non-essential travel (everyone in the home where the traveller is self-isolating needs to self-isolate)
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I am committed in taking the necessary measures to protect my health and safety and that of my co-workers. Furthermore, I am committed to respect the guidelines issued by Public Health
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as well as in the progressive resumption protocol established in the COVID-19 Health and Preventive Measures for Return to Work Protocol
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I am committed to inform my manager immediately of any change in my state of health. I hereby confirm that my statement is authentic
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Employee Signature:
