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

Do you have two or more of the following – new or worsening symptoms? (NOT attributed to any other causes such as allergies, asthma, or other known causes or conditions) Please select all that apply.*

New onset or worsening cough or difficulty breathing
Sore throat, difficulty swallowing
Headache
Runny nose, nasal congestion
Digestive issues (Nausea, vomiting, diarrhea, and/or abdominal pain)
Muscle aches, chills, fatigue/malaise
Decrease or loss of sense of smell, or taste or both
Conjunctivitis (Pink eye)
I do not have TWO OR MORE of the above symptoms

Have you been tested for COVID-19 recently that you have not reported to Work Clearance?*

Yes
No

Have you returned from travel outside of Ontario that you have not reported to Work Clearance?*

Yes
No

Have you been in direct contact with someone returning from travel outside of Ontario that you have not reported to Work Clearance?*

Yes
No

Does anyone in your household have COVID-19 symptoms that you have not reported to Work Clearance?*

Yes
No

Have you had close contact with anyone with a new respiratory illness or a confirmed or probable case of COVID-19 that you have not reported to Work Clearance? (without proper use of Personal Protective Equipment)*

Yes
No

Have you been contacted by Work Clearance and they have directed that you are NOT CLEARED to work?*

Yes
No

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.*

Employee Acknowledgement 2

I hereby consent to including my supervisor(s)/manager(s) in any communication from Work Clearance.

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

COVID-19 DAILY EMPLOYEE SURVEY - UPDATED OCT 2021

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