Daily Screening Questionnaire

For employee use ONLY.  Any patron entering a Town facility will be asked for additional information upon entering any municipal building.

Please answer these questions before you enter any Town facility.

For Town of LaSalle and LaSalle Police Services Staff: If you are experiencing any COVID-19 Symptoms, do not come to work.

Please fill out this form, call your supervisor and stay home.

Please read the following and answer below:

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?

• Fever and/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 taste or smell
  • 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

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.”

• I consent to the Town’s collection of my personal information for the purpose described in the notice of collection (above);
• That the information that I provided is accurate and truthful; and,
• That this information may be disclosed to the Windsor-Essex County Health Unit in the event that the Health Unit requests the information from the Town.