Fillable COVID-19 Customer and Client Screening (Workers' Safety and Compensation Commission)

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COVID-19 Customer and Client Screening (Workers' Safety and Compensation Commission)

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The COVID-19 Customer and Client Screening (Workers' Safety and Compensation Commission) form is 1 page long and contains:

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  • 16 check-boxes
  • 8 other fields

Country of origin: CANADA
File type: PDF

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COVID-19 Customer and Client Screening
Workplaces and workers must follow public health orders
• NT: https://www.gov.nt.ca/covid-19/en/covid-19
• NU: https://gov.nu.ca/health/information/covid-19-novel-coronavirus
Use this tool to determine if a customer or client presents a risk of exposing anyone in the workplace to
COVID-19.
1. Screen for risks of exposure to COVID-19 according to your Exposure Control Plan.
2. Inform the person of rules they must follow:
a. check-in procedure
b. use of face coverings
c. hand washing or sanitizing
d. controlled movement within the spac
e
e. check-out procedure
3. For clients who answer “Yes”, assess the risk and follow your Exposure Control Plan
.
Client’s Name:
Name of person conducting screening:
☐
Self-screen
Date and time of screening:
☐ Over the phone
☐
At entry of the business
☐ Email (self-screen)
Date and time of service or appointment:
Service being provided:
Name of worker performing service:
Supervisor’s name:
1. Do you have any symptoms of COVID-19 (such as cough, fever, difficulty breathing)?
☐
No – Proceed to 2.
☐
Yes – Assess the risk and follow your Exposure Control Plan.
2. Have you recently travelled out of the Territory?
☐
No – Proceed to 3.
☐
Yes – Assess the risk and follow your Exposure Control Plan.
3. Have you been in close contact with:
• someone confirmed to have COVID-19;
• someone who is being investigated for COVID-19;
• someone who has symptoms
of COVID-19; or,
• someone who has recently travelled out of the Territory?
☐
No – Proceed to 4.
☐
Yes – Assess the risk and follow your Exposure Control Plan.
4. Inform person of rules in place for:
☐
Check-in
☐
Hand washing
☐
Sanitizing between clients
☐
Use of face covering
☐
Controlled movement in space
☐
Check-out
Other considerations:
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COVID-19 Customer and Client Screening (Workers' Safety and Compensation Commission)

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Completed 1 March 2021

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