LTC COVID-19 ENHANCED STUDENT/INSTRUCTOR SCREENING QUESTIONNAIRE
Updated: November 9, 2020
NEW STUDENTS/INSTRUCTORS WHO ARE NEW TO THE SITE OR HAVE BEEN AWAY FROM THE SITE FOR MORE THAN 14
DAYS , MUST COMPLETE THIS FORM 3 BUSINESS DAYS PRIOR TO THEIR FIRST SHIFT AND SUBMIT IT TO THEIR DIRECTOR
OF CARE OR MANAGER.
Student/Instructor Name: _____________________________________ Phone Number: _______________________
Date of first planned shift: _________________________ Facility Name: ___________________________________
1. Have you ever been diagnosed with COVID-19?
☐ YES ☐ NO
2. In the last 14 days, to your knowledge, have you been in contact with anyone with COVID-19 and/or have you traveled outside
of Canada, including the Unites States?
☐ YES ☐ NO
3. In the last 14 days, did you work at a facility experiencing an outbreak of COVID-19?
☐ YES ☐ NO
4. Please list the healthcare facility and/or unit you have worked in during the last 14 days:
_______________________________________________________________________________________
5. Do you have any of the following symptoms?
☐ Runny nose or congestion
☐ Loss of appetite/nausea
☐ Sore throat/painful swallowing
☐ Muscle aches, fatigue, or weakness
I certify that the above is true to the best of my knowledge.
Student/Instructor Name: ____________________________ DOC/Manager Name: _______________________________
Student/Instructor Signature: _________________________ DOC/Manager Signature: ____________________________
Date: _____________________________________________Date: ____________________________________________
DOC/Manager Phone Number: _____________________
WHAT TO DO WITH THIS FORM:
3 business days prior to their first shift, student/instructor must complete this form, sign it (either on paper or electronically) and:
If Group Student: send it to the Group Instructor. The Instructor will need to submit the completed forms for their group
to DOC/Manager at least 3 business days prior to their first scheduled shift.
If Preceptorship Student: send it to their DOC/Manager at least 3 business days prior to their first scheduled shift.
DOC/Manager must ensure the form is fully completed and fax to VCH Public Health at 604-731-2756 a minimum of 24 hours
prior to their scheduled shift.
If you have checked YES to any of the above, student/instructor is to notify their DOC/Manager. The DOC/Manager may not schedule
student/instructor for practicum until cleared by Public Health.
• VCH Public Health will call student/instructor directly to identify earliest possible start date
• Student/instructor with any symptoms should seek COVID-19 testing, while awaiting a call from VCH Public Health
• If an urgent assessment is needed, please call Public Health at 604-675-3900 and have your PHN ready
If NO to all questions, proceed with planned shift.
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