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

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

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

  • 0 signatures
  • 18 check-boxes
  • 5 other fields

Country of origin: CANADA
File type: PDF

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Keep screening information for your records.
COVID-19 Worker 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 form if you need to screen workers before they come to work. You must determine whether the
worker presents a risk of exposing anyone at the site to COVID-19.
1. Screen for risks of exposure to COVID-19 according to your Exposure Control Plan
2. Inform the worker of safe work procedures they must follow:
a. check in procedure
b. use of Personal Protective Equipment (PPE)
c. hand washing or hand sanitizing
d. cleaning surfaces (before and after use)
e. controlled movement within the space
f. check out procedure
3. Keep worker screening information in your files.
Worker’s Name:
Name of person conducting screening:
☐ Self-screen
Date and time of screening:
☐
At entry of the business
☐
Over the phone
☐
Email (self-screen)
Supervisor’s name:
1. Does the worker 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.
Inform the worker to follow all relevant public health orders.
2. Has the worker recently travelled out of the Territory?
☐
No – Proceed to 3.
☐
Yes – Assess the risk and follow your Exposure Control Plan.
Inform the worker to follow all relevant public health orders.
3. Does the worker work or volunteer at another work place considered to be high risk?
☐ No – Proceed to 4. ☐ Yes – Assess the risk to determine additional safety requirements.
Proceed to 4.
4. Has the worker 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 5.
☐
Yes – Inform the worker to follow all relevant public health orders.
5. Has the worker been informed of safe work procedures for:
☐
2-meter distancing
☐
Hand washing or sanitizing
☐
Check in/out process
☐
Controlled movement in space
☐
Cleaning surfaces
☐
Use of PPE
Other considerations:
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COVID-19 Worker Screening (Workers' Safety and Compensation Commission)

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Completed 1 March 2021

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