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COVID-19 Symptom reporting form

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Bloc formulaire

This questionnaire aims to screen workers before entering their workplace to exclude those who are symptomatic and who have not had contact with a known case of COVID-19 already followed by public health authorities.

The questionnaire is intended to be completed by employees themselves on their workplace (other than health care facilities) to ensure the rapid removal of workers potentially infected with COVID-19 and to prevent its transmission to others in the workplace.

Employees with positive answers in their questionnaires should call 1 877 644 4545 or 811 to receive instructions (alternatively, check www.quebec.ca(link is external) for local phone numbers). When calling, the person should specify that he/she is a worker.

Anyone present at the site must fill out this form every day before the start of their working day.

Update February 1, 2021 - Version 5

Fields marked with an asterisk are required.

First name *

Last name *

E-mail adress *

Phone number *

You're a : *

Select the reason of your presence

Do you feel feverish, have flu-like chills, or a fever with an oral temperature of 38.1°C (100.6°F) or higher? *

Do you have any of the following symptoms: A recent cough, difficulty breathing, unusual headache, sore throat, runny nose, or nasal congestion (stuffy nose) of unknown cause? *

Have you been exposed to a person who has a confirmed or probable case of COVID-19 infection? *

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A&R Brochu Construction

COVID-19 Symptom reporting form