CIC COVID Safety Survey – Columbia International College

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For the purpose of contact tracing, the ability to proactively screen for exposure, and to prevent cross contamination, we are requesting that each employee completes this short COVID-19 Symptoms Survey.

For the survey information to be the most updated, we would like you to complete the survey on a daily basis before going to work.

The survey is a way to increase and improve our screening protocols.

Please be assured that this survey will remain confidential within Human Resources and the Nurse Supervisor. Your answers will not be shared without your consent.

If our Nurse Supervisor finds some concern based on your responses:

1. You will be provided with actions to be taken.
2. You may be required to stay at home or self-isolate for up to 14-days.

Return to work decisions are made by our Nurse Supervisor:

1. in the context of local circumstances and
2. reviewed on a case-by-case basis

We are working continuously to improve our protection of the CIC community of students and employees from COVID-19. For this survey to be an effective proactive screening tool for the virus exposure, your candid answers are much appreciated.

Thank you for your time and cooperation in completing the survey.

HR Director

Name*

First Last

Department*

Email*

Phone*

Do you feel like or have a fever of 37.8 °C (100.04°F) or higher? (Your temperature will be taken at the front entrance screening)*

Yes
No

Are you currently experiencing any of these COVID-19 symptoms?*

Do you have any of these other atypical COVID-19 Symptoms?*

Chills
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
Pink eye
No, I do not have any of the above symptoms

Have you been tested for COVID-19 in the last two weeks that you have pending or positive results?*

Yes
No

Location of Assessment Center*

Date of test*

Have you traveled out of Ontario in the past 14 days?*

Yes
No

Have you reported this to Work Clearance?*

Yes
No

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Date of return to Ontario

Have you been in contact with someone who has traveled out of Canada in the past 14 days (excluding CIC students)?*

Yes
No

Date of contact with person who has travelled outside of Canada*

Have you had close contact with anyone with a new respiratory illness or a confirmed or probable case of COVID-19?*

Yes
No

Date of contact with ill person*

In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? (If you already went for a test and got a negative result, select “No.”)*

Yes
No

Have you been to the following facilities since the last time you completed this survey? Please check all that apply.*

Any emergency department
Any urgent care centre
Facilities with an active outbreak
None of the above

Name of facilities visited:*

Date last visited these facilities:*

Are you fully vaccinated*

Yes
No
I Prefer Not To Say

Are you planning to come into work today?*

Yes
No

Today is a Wednesday so new questions are needed:

Please indicate if you currently work, volunteer, and/or have visited any of the following facilities listed below in the last 14 days. Please check as many as appropriate.*

Hospitals
Nursing Homes
Long Term Care Facilities
Retirement Homes
Prisons
Shelters
Other
No, I have not visited any of the above places

Name of hospital(s) visited:*

Latest date of hospital visit:*

Name of nursing home(s) visited:*

Latest date of nursing home visit:*

Name of long term care facility(facilities) visited:*

Latest date of long term care facility visit:*

Name of retirement home(s) visited:*

Latest date of retirement home visit:*

Name of prison(s) visited:*

Latest date of prison visit:*

Name of shelter(s) visited:*

Latest date of shelter visit:*

Name of other facility(facilities) visited:*

Latest date of visit to other facility:*

Do any of your household member(s) work, volunteer, and/or have visited any of the following facilities listed below in the last 14 days? Please check as many as appropriate.*

Name of the facility(facilities) visited:*

Latest date of visit to these facilties:*

Is any of your household members a first responder (Categories include: paramedics, emergency medical technicians, police officers, firefighters, etc.)?*

Yes
No

Please specify the category of first responder:*

Please specify the location they work/service:*

Employee Acknowledgement:

Employee Acknowledgement*

I hereby certify that the answers I have provided in this COVID-19 Risk Mitigation Employee Survey are true and accurate.*

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Employee Acknowledgement 2

I acknowledge that I have the duty to report and must make every effort possible to inform Human Resources immediately if anything changes after submitting this survey.

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Employee Acknowledgement 3

If I neglect to inform Human Resources, I understand that I may be subject to disciplinary action.

Thank you for proactively contributing to the prevention of COVID-19 in the CIC community.

COVID-19 DAILY EMPLOYEE SURVEY

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