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Purpose of the visit:
Akler Browning LLP has implemented a health and safety plan for operation in alignment with local Public Health Guidelines, Health and Safety regulations, and any applicable legislation in Ontario. To ensure the safety of our employees, all individuals visiting our premises at 700-5255 Yonge Street, Toronto must complete the following screening questionnaire. We appreciate your cooperation in sharing this information as strives towards creating a safe environment for all employees and visitors.
Symptoms should not be chronic or related to other known causes or conditions. For individuals who are 18 years of age and older.
YesNo
Fever and/or chills
Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
Cough or barking cough (croup)
Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have
Shortness of breath
Not related to asthma or other known causes or conditions you already have
Sore throat
Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have
Difficulty swallowing
Painful swallowing not related to other known causes or conditions you already have
Decrease or loss of smell or taste
Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have
Pink eye
Conjunctivitis (not related to reoccurring styes 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
Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have). If you received a COVID-19 vaccination in the last 48 hoursand are experiencing a mild headache that only began after vaccination, select “No.”
Digestive issues like nausea/vomiting, diarrhea, stomach pain
Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have
Muscle aches/joint pain
Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have). If you received a COVID-19 vaccination in the last 48 hoursand are experiencing mild muscle aches/joint pain that only began after vaccination, select “No.”
Fatigue
Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have). If you received a COVID-19 vaccination in the last 48 hoursand are experiencing mild fatigue that only began after vaccination, select “No.”
Falling down often
For older people
This can be because of an outbreak or contact tracing.
If you have since tested negative on a lab-based PCR test, select “No.”
If public health has advised you that you do not need to self-isolate (e.g., you are fully vaccinated* or another reason), select “No.”
Fully vaccinated is defined as an individual ≥14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series.
If you are fully vaccinated or have already gone for a test and got a negative result, select “No.”
If you are fully vaccinated, select “No.”
If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”
If you answered NO to all questions from 1 through 7 you may enter the workplace.
If you answered YES to any questions from 1 through 7 you must not enter the workplace, inform your contact at Akler Browning of the result and stay home and contact your healthcare provider or Telehealth Ontario to get advice.
If you answered YES to question 7 you must stay home, along with the rest of the household, until the sick individual gets a negative COVID-19 test result, is cleared by your local public health unit or is diagnosed with another illness.
Upon visiting the workplace, you expressly agree to abide by all Health and Safety measures implemented by Akler browning LLP.
Please submit this form prior to physically vising the Akler Browning LLP by clicking the submit button below.
I attest that the information above is accurate. I agree to abide by the procedures outlined above.
Signature: (required). Draw with your mouse or finger (touchscreen only).
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