Self-Screening Tool

This checklist below is meant to keep you and your colleagues healthy. It is only a basic
checklist and not meant to take the place of medical advice, diagnosis or treatment.
Employees are required to self-screen prior to the start of every shift



Please provide the following information.

First Name:

Last Name:

Email Address:

Employee Number:

Supervisor's Email:


Screening Questions

Do you have any of the following symptoms: fever, new cough, difficulty breathing, or a combination of these symptoms?

Have you just returned from outside of Canada within the last 14 days?

Have you been advised by the public health authority, BC COVID-19 Symptom Self-Assessment Tool or your family physician to self-monitor or self-isolate in the last 14 days?

Have you been in close contact with a person who has been confirmed with or probable COVID-19 case (family or friend that you live with) in the last 14 days?


COVID-19 Self-Screening Tool originally developed for the City of Surrey by TheWGroup.ca, powered by ClikHere.ca