COVID PRE-SCREENING FORM

This screening tool has been issued by the Office of the Chief Medical Officer of Health, Government of Ontario.

This is a mandatory form and must be fill out prior to entering any Fidelity work site or building.

Thank you for your cooperation in keeping Fidelity sites safe for our contractors, employees and all visitors.

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NOTE: A person is fully vaccinated against COVID-19 if,

(a) they have received,

(i) the full series of a COVID-19 vaccine authorized by Health Canada, or any combination of such vaccines,

(ii) one or two doses of a COVID-19 vaccine not authorized by Health Canada, followed by one dose of a COVID-19 mRNA vaccine authorized by Health Canada, or

(iii) three doses of a COVID-19 vaccine not authorized by Health Canada; and

(b) they received their final dose of the COVID-19 vaccine at least 14 days before seeking access to the premises

Name *

First

Last

Company Name *

Phone Number *

Email *

Are you fully vaccinated against COVID-19? (See definition of fully vaccinated at the top of the page)

Are you currently experiencing any of these issues? Call 911 if you are.

Severe difficulty breathing (struggling for each breath, can only speak in single words) / Severe chest pain (constant tightness or crushing sensation) / Feeling confused or unsure of where you are Losing consciousness

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have. (The symptoms listed here are the most commonly associated with COVID-19. Anyone who is sick or has any symptoms of illness, including those not listed below, should stay home and seek assessment from their health care provider if needed.) *

Fever or chills (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher)
Cough or barking cough (croup) - Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)
Shortness of breath - Out of breath, unable to breathe deeply (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)
Muscle aches/joint pain - Unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)
Extreme tiredness - Unusual, fatigue, lack of energy (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)
Sore throat - Painful or difficulty swallowing (not related to post-nasal drip, acid reflux, or other known causes or conditions you already have)
Runny or stuffy/congested nose - Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have
Headache - New, unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, tension-type headaches, chronic migraines, or other known causes or conditions you already have)
Nausea, vomiting and/or diarrhea - Not related to irritable bowel syndrome, anxiety, menstrual cramps, medication side effects, or other known causes or conditions you already have
I feel well and am not experiencing any symptoms listed above

In the last 10 days, has someone you live with: been sick with symptoms associated with COVID-19? and/or tested positive for COVID-19 (on a rapid antigen test or PCR test)? *

In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit? *

In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? *

In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19 (confirmed by a PCR or rapid antigen test)? If public health has advised you that you do not need to self-isolate, select “No.” *

In the last 14 days, have you travelled outside of Canada? If exempt from federal quarantine requirements as directed by the border agent at your point of entry (for example, you have two or more doses of a COVID-19 vaccine and have met the specific conditions, or an essential worker who crosses the Canada-US border regularly for work), select “No.” *

Services

Heavy Civil Construction
Residential Construction & Homes
Communities & Developments
Concrete Forming
Materials & Landscape Supplies
Waste Services

contact

Get in touch with Fidelity through our
contact page or call 1-888-468-5768

Head Office
512 Purdy Road
Colborne, Ontario K0K1S0

services

Heavy Civil Construction
Residential Construction & Homes
Communities & Developments
Concrete Forming
Materials & Landscape Supplies
Waste Services

contact

Email Us
1-888-468-5768

Head Office
512 Purdy Road
Colborne, Ontario K0K1S0