Introduction:

This checklist template is part of our Coronavirus Workplace Processes pack.

It was built following the procedures outlined by the Emergency Coordination Centre (ECC) at Alberta Health Services.

Essential workers are at very high risk of exposure compared to those in other professions. This means there's always a risk for staff and customers if employees attend work while experiencing COVID-19 symptoms. To minimize the spread of viruses, we built this checklist to help screen essential personnel for fitness for work based on COVID-19 symptoms and exposure risks. This checklist should be completed prior to personnel reporting to their workplace to ensure employees are attending work in good health and helping keep the rest of your staff and customers safe.

You can edit this template with form fields and widgets to better suit your team's needs. This template makes use of Process Street features like: conditional logic, dynamic due dates, and stop tasks to encourage team compliance and allow for variable outcomes depending on the answers given in the screening. 

When you're ready to put your template into action, simply run the template as a checklist.

Process Street is not a medical institution and the items contained in this process template are illustrative and not intended to be understood as medical advice. Please refer to the attached PDF document for any and all medical or operational recommendations.

Record basic details

Use the form fields below to record basic information about the person being screened.

Answer screening questions

All essential personnel are required to complete a screening before starting a shift, by completing the following questionnaire to assess health risk:

1. Do you have any of the following symptoms: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose?

2. Have you returned to the United States from outside the country in the past 14 days?

In the past 14 days, at work or elsewhere, while not wearing appropriate personal protective equipment:

3. Did you have close contact with a person who was ill or had a confirmed case of COVID-19?

In the past 14 days, at work or elsewhere, while not wearing appropriate personal protective equipment:

4. Did you come into close contact with a person who had an acute respiratory illness that began within 14 days of their close contact to someone who was ill or had a confirmed case of COVID-19?

In the past 14 days, at work or elsewhere, while not wearing appropriate personal protective equipment:

5. Did you come into close contact with a person who had an acute respiratory illness who returned from travel outside of the United States in the 14 days before they became sick? 

In the past 14 days, at work or elsewhere, while not wearing appropriate personal protective equipment:

6. Did you have a laboratory exposure to biological material (i.e. primary clinical specimens, virus culture isolates, etc.) known to contain COVID-19?

[Conditional] Advise personnel to self-isolate

If the personnel answered “Yes” to any of the questions, advise them to not attend work or visit the workplace at this time and to self-isolate at their home.

[Conditional] Advise personnel to proceed to work

If the personnel answered “No” to all of the questions, advise them to work as normal.

If they begin to develop any new symptoms, redo the questionnaire to reevaluate their  fitness to work.

Note: If they're experiencing any other new symptoms that weren't listed in the questionnaire, then they should stay home and minimize close contact with others until the symptoms pass.

Approval: Final approval

Will be submitted for approval:
  • [Conditional] Advise personnel to self-isolate
    Will be submitted
  • [Conditional] Advise personnel to proceed to work
    Will be submitted

Sources:

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