Highline Mushrooms COVID 19 Employee Screening Questionnaire

• Site conducted

  Select

• Employee Name

• Associate Number

• Date

  Date
Temperature Scan Results
• Location
  Address

• Received a Highline Mushrooms approved mask?

• If an employee answers “Yes” to any of the screening questions, immediately activate Highline's COVID-19 emergency protocol. The screener should:
  
  • Ensure the screening results are accurate.
  • Ask the employee to go home and call their primary care physician.
  • Notify management.

EMPLOYEE SCREENING QUESTIONNIARE

• 2. Have you been medically directed to self-quarantine by a health care provider or public health unit?

  Yes

  No

  N/A

• 3. In the last 72 hours, have you had any of the following: a new fever of 100.4°F or 37.7 C or greater, a new or worsening cough, shortness of breath, sore throat, new muscle aches or a loss of taste or smell, pink eye, runny or stuffy nose, headache, digestive issues such as nausea, diarrhea, stomach pain, muscle aches, extreme tiredness, falling down?

  Yes

  No

  N/A

• Do not entre the workplace. Leave the workplace immediately, go home and call HR for further instructions.

• 1. In the last 14 days have you or someone in your household or workplace been in close contact with a person who has or is a probable positive case of COVID-19?

  Yes

  No

  N/A

• Do not entre the workplace. Leave the workplace immediately, go home and call HR for further instructions.

• In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?

  Yes

  No

  N/A

• Do not entre the workplace. Leave the workplace immediately, go home and call HR for further instructions.

• In the last 14 days, have you or anyone you live with travelled outside of Canada?

  Yes

  No

  N/A

• Are you or anyone you live with currently experiencing any new or worsening symptoms of COVID-19 or awaiting a COVID-19 test result?

  Yes

  No

  N/A

• Do not entre the workplace. Leave the workplace immediately, go home and call HR for further instructions.

• 4. Do you have a clean face mask approved for use at a Highline location?

  Yes

  No

  N/A

• Do not entre the workplace. Leave the workplace immediately, go home and call HR for further instructions.

SIGN OFF

• Monitor/Screening Associate Signature

  Sign

• Employee Signature

  Sign