Are you working / volunteering in any other SHA facility (not LTC) for any period of time today?

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Are you experiencing any of the following:

  • severe difficulty breathing (e.g., struggling for each breath, speaking in single words)
  • severe chest pain
  • having a very hard time waking up
  • feeling confused
  • lost consciousness
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Are you experiencing any of the following:

  • short of breath at rest
  • inability to lie down because of difficulty breathing
  • chronic health conditions that you are having difficulty managing because of your current respiratory illness
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The rest of this assessment will ask you questions to determine whether or not you will require COVID-19 testing.

Do you have any of the following:

• Fever• Muscle or joint aches and pains
• Cough• Loss of sense of smell or taste
• Shortness of breath• Dizziness
• Sore throat• Nausea
• Chills • Vomiting
• Headache• Diarrhea
• Runny nose• Loss of appetite (or difficulty feeding for children)
• Conjunctivitis• Fatigue
• Nasal congestion
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Were you exposed to someone who is under investigation for COVID-19 or has been confirmed as having COVID-19 within 14 days of your symptoms starting?

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Did you travel internationally within 14 days of your symptoms starting?

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Were you exposed to someone who is under investigation for COVID-19 or has been confirmed as having COVID-19 within the last 14 days?

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In the past 14 days have you returned from international travel?

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Attention

  • The SHA requires you to answer the following questions to assist in determining your fitness to work during COVID-19.
  • You have the option to complete the screening questions online, no more than 2 hours prior to starting work.
    • If you do not have access to the online tool, you will have the option to answer the questions on site.
    • The results of this screening tool are valid for 24 hours providing you remain asymptomatic.
  • We are not screening for seasonal or environmental allergies; related symptoms to these scenarios would not preclude you from work. The following questions are meant to capture new symptoms, or a worsening of long-standing symptoms.


The information collected by this questionnaire will be used and disclosed solely for the purposes of screening for fitness for work during the COVID-19 pandemic in accordance with the SHA’s obligations to provide a safe work and clinical environment for all.

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SHA Health Care Worker Screening Tool

Do you have any of the following symptoms?
Reminder: we are not screening for seasonal or environmental allergies

  • Fever (temperature ≥ 38.0 Celsius)
  • New or worsening respiratory symptoms i.e. cough, shortness of breath or difficulty breathing, sore throat, runny nose?
  • New onset atypical symptoms including chills, aches and pains, headache, loss of sense of smell or taste?
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SHA Health Care Worker Screening Tool

Have you tested positive for COVID-19?

NOTE: if you’ve been cleared to go back to work by Occupational Health and Safety, Employee Health, or Public Health answer NO

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SHA Health Care Worker Screening Tool

In the last 14 days,

  • Have you been outside of Canada, including to the United States?
    NOTE: If you have an approved travel exemption answer NO – be prepared to provide documentation regarding the exemption
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SHA Health Care Worker Screening Tool

In the last 14 days,

  • Have you had close contact with a confirmed or probable case of COVID-19?
    NOTE: If you’ve been cleared to go back to work by Occupational Health and Safety, Employee Health, or Public Health answer NO


Consult the Covid-19 Definitions Handout for definitions of close contact, non-close contact, confirmed case and probable case.

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SHA Health Care Worker Screening Tool

In the last 14 days,

  • have you lived in or visited a community or facility deemed an area of concern* for COVID-19?
Current area of concern list found in the Daily Fitness for Work Screening section of saskatchewan.ca/COVID-19
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SHA Health Care Worker Screening Tool

Do ANY of these apply to you?

In the last 14 days

  • You have travelled outside Saskatchewan but within Canada
  • You have been outside of Canada, including to the United States (with an approved travel exemption)
  • You have had NON-close contact with a confirmed or probable case of COVID-19
  • You spent prolonged time (i.e. >15 min) with people outside your extended household where you were not able to maintain physical distance or use appropriate PPE for the situation (note: appropriate PPE includes cloth masks for non-medical situations)


Consult the Covid-19 Definitions Handout for definitions of close contact, non-close contact, confirmed case and probable case.

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Are you working / volunteering in a Long Term or Continuing Care Home or affiliate facility for any period of time today?

Attention

  • The SHA requires you to answer the following questions to assist in determining your fitness to work during COVID-19.
  • You have the option to complete the screening questions online, no more than 2 hours prior to starting work.
    • If you do not have access to the online tool, you will have the option to answer the questions on site.
    • The results of this screening tool are valid for 24 hours providing you remain asymptomatic.
  • We are not screening for seasonal or environmental allergies; related symptoms to these scenarios would not preclude you from work. The following questions are meant to capture new symptoms, or a worsening of long-standing symptoms.
  • Because you work with a highly vulnerable population, you are required to actively self-monitor (temperature log twice daily for yourself and monitor symptoms). This is in addition to the screening at your worksite.


The information collected by this questionnaire will be used and disclosed solely for the purposes of screening for fitness for work during the COVID-19 pandemic in accordance with the SHA’s obligations to provide a safe work and clinical environment for all.

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SHA LTC Screening Tool

Do you have any of the following symptoms?
Reminder: we are not screening for seasonal or environmental allergies

  • Temperature ≥ 37.8°C or 100.0°F
  • New or worsening respiratory symptoms i.e. cough, shortness of breath or difficulty breathing, runny nose or sneezing, nasal congestion, hoarse voice, sore throat or difficulty swallowing
  • Any new onset atypical symptoms including but not limited to chills, muscle aches, diarrhea, malaise, fatigue, headache, or loss of sense of smell or taste
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SHA LTC Screening Tool

Have you tested positive for COVID-19?

NOTE: if you’ve been cleared to go back to work by Occupational Health and Safety, Employee Health, or Public Health answer NO

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SHA LTC Screening Tool

In the last 14 days,

  • Have you been outside of Canada, including to the United States?
    NOTE: If you have an approved travel exemption answer NO – be prepared to provide documentation regarding the exemption
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SHA LTC Screening Tool

In the last 14 days,

  • Have you had close contact with a confirmed or probable case of COVID-19?
    NOTE: If you’ve been cleared to go back to work by Occupational Health and Safety, Employee Health, or Public Health answer NO


Consult the Covid-19 Definitions Handout for definitions of close contact, non-close contact, confirmed case and probable case.

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SHA LTC Screening Tool

In the last 14 days,

  • have you lived in or visited a community or facility deemed an area of concern* for COVID-19?
Current area of concern list found in the Daily Fitness for Work Screening section of saskatchewan.ca/COVID-19
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SHA LTC Screening Tool

Do ANY of these apply to you?

In the last 14 days

  • You have travelled outside Saskatchewan but within Canada
  • You have been outside of Canada, including to the United States (with an approved travel exemption)
  • You have had NON-close contact with a confirmed or probable case of COVID-19
  • You spent prolonged time (i.e. >15 min) with people outside your extended household where you were not able to maintain physical distance or use appropriate PPE for the situation (note: appropriate PPE includes cloth masks for non-medical situations)


Consult the Covid-19 Definitions Handout for definitions of close contact, non-close contact, confirmed case and probable case.

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Please call 911 or go directly to your nearest emergency department.

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Please go directly to your nearest emergency department. If your symptoms worsen, call 911.

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Mandatory Self-Isolation
Please Call HealthLine 811.

All travellers returning from international destinations are subject to a mandatory self-isolation order under the Public Health Order (March 20, 2020). Violation of the order may result in a fine.

Based on the responses you've just provided, please call HealthLine 811 to have your symptoms assessed.

Please do not go to an emergency department, family doctor or walk-in clinic unless your symptoms worsen.

Visit https://www.saskatchewan.ca/coronavirus for more information

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Self Isolation
Please Call HealthLine 811.

Based on the responses you've just provided, please call HealthLine 811 to have your symptoms assessed and to determine if you require testing for COVID-19.

Visit https://www.saskatchewan.ca/coronavirus for more information

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Mandatory Self Isolation
Call 811 for additional information
Since you don’t have any COVID-19 symptoms, you don’t need to be tested for COVID-19.

All travellers returning from international destinations are subject to a mandatory self-isolation order under the Public Health Order (March 20, 2020). Violation of the order may result in a fine.

If you get any COVID-19 symptoms, take this self-assessment again.

If you are experiencing other symptoms and want assessment, contact HealthLine 811.

Visit https://www.saskatchewan.ca/coronavirus for more information

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You may need to Mandatory Self Isolate
Please call 811 for further assessment
Since you don’t have any COVID-19 symptoms, you don’t need to be tested for COVID-19.

Anyone identified as a close contact of someone with COVID-19 shall go into mandatory self-isolation for 14 days from the date of having been exposed under the Public Health Order (March 20, 2020). Violation of the order may result in a fine.

If you get any COVID-19 symptoms, take this self-assessment again.

If you are experiencing other symptoms and want assessment, contact HealthLine 811.

Visit https://www.saskatchewan.ca/coronavirus for more information

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Since you don’t have any COVID-19 symptoms, you don’t need to be tested for COVID-19.

However, there’s a chance you could get sick since it’s less than 14 days since your exposure. You should self-isolate until 14 days after the exposure. Self-isolation means don’t go to any public places, stay at home, and don’t have any visitors. If you have questions, visit https://www.saskatchewan.ca/coronavirus.

If you get any COVID-19 symptoms, take this self-assessment again.

If you are experiencing other symptoms and want assessment, contact HealthLine 811. We are experiencing heavy call volumes and will get to your call as quickly as we can.

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Self-Monitor

Testing is available to Saskatchewan residents that work outside the home or are immunocompromised. You may request testing by calling HealthLine 811.

If you are experiencing symptoms and want assessment, contact HealthLine 811.

If you get any COVID-19 symptoms, take this self-assessment again.

Visit https://www.saskatchewan.ca/coronavirus for more information

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Since you don’t have any COVID-19 symptoms, you don’t need to be tested for COVID-19.

If you get any COVID-19 symptoms, take this self-assessment again. If you need more information, visit https://www.saskatchewan.ca/coronavirus

If you are experiencing other symptoms and want assessment, contact HealthLine 811. We are experiencing heavy call volumes and will get to your call as quickly as we can.

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SHA Health Care Worker Screening Tool
NOT PERMITTED TO WORK


Based on the answers to your Screening Assessment you need to immediately self isolate and you are NOT permitted to work

  • You are required to self-isolate until you receive further instructions
  • Contact your manager / supervisor to inform them of your screening results
  • Take a screenshot/picture of your result to send to your manager/supervisor if able
  • Contact OH&S Hotline at 1-833-233-4403 for further instructions
    • Based on your results, you need to be tested for Covid-19
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SHA Health Care Worker Screening Tool
NOT PERMITTED TO WORK


Based on the answers to your Screening Assessment you need to continue to self isolate and you are NOT permitted to work

  • You are required to self-isolate until you receive further instructions
  • Contact your manager / supervisor to inform them of your screening results
  • Take a screenshot/picture of your result to send to your manager/supervisor if able
  • Contact OH&S Hotline at 1-833-233-4403 for further instructions
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SHA Health Care Worker Screening Tool
NOT PERMITTED TO WORK


Based on the answers to your Screening Assessment you need to mandatory self isolate and you are NOT permitted to work

  • You are required to self-isolate for 14 days
    • All travellers returning from international destinations are subject to a mandatory self-isolation order under the Public Health Order (March 20,2020). Violation of the order may result in a fine.
  • Contact your manager / supervisor to inform them of your screening results
  • Take a screenshot/picture of your result to send to your manager/supervisor if able
  • Contact OH&S Hotline at 1-833-233-4403 for further instructions
    • You do NOT need to be tested for Covid-19 as you do not have symptoms
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SHA Health Care Worker Screening Tool
PERMITTED TO WORK – Self Monitor


Based on the answers to your Screening Assessment, you ARE permitted to work BUT need to self-monitor

  • You are required to self-monitor and maintain a physical distance while working and on breaks
  • If you are unable to maintain appropriate physical distance, you should mask even if not in clinical areas or zones
  • Self-monitoring includes temperature checks, pre and post shifts
  • Please take a screenshot/picture of this result and present it to the screening staff on arrival to your workplace if you are able.
  • Ensure you are always following hand hygiene protocols and cleaning your keys, phone, computer and other personal items.
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SHA Health Care Worker Screening Tool
NOT PERMITTED TO WORK


Based on the answers to your Screening Assessment you need to mandatory self isolate and you are NOT permitted to work

  • You are required to self-isolate for 14 days
    • Anyone identified as a close contact of someone with COVID-19 shall go into mandatory self-isolation for 14 days from the date of having been exposed under the Public Health Order.
  • Contact your manager / supervisor to inform them of your screening results
  • Take a screenshot/picture of your result to send to your manager/supervisor if able
  • Contact OH&S Hotline at 1-833-233-4403 for further instructions
    • You do NOT need to be tested for Covid-19 as you do not have symptoms
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SHA Health Care Worker Screening Tool
PERMITTED TO WORK – Self Monitor


Based on the answers to your Screening Assessment, you ARE permitted to work BUT need to self-monitor

  • You are required to self-monitor
    • If you have travelled, you are required to self-monitor 14 days from your return date
    • If you have had a non-close contact, you are required to self-monitor 14 days from your last exposure
  • Self-monitoring includes temperature checks, pre and post shifts
  • Please take a screenshot/picture of this result and present it to the screening staff on arrival to your workplace if you are able.
  • Ensure you are always following hand hygiene protocols and cleaning your keys, phone, computer and other personal items.
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SHA Health Care Worker Screening Tool
PERMITTED TO WORK


Based on the answers to your Screening Assessment, you ARE permitted to work

  • Please take a screenshot/picture of this result and present it to the screening staff on arrival to your workplace if you are able.
  • Ensure you are always following hand hygiene protocols and cleaning your keys, phone, computer and other personal items.
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LONG TERM CARE TOOL
NOT PERMITTED TO WORK


Based on the answers to your Screening Assessment you need to immediately self isolate and you are NOT permitted to work

  • You are required to self-isolate until you receive further instructions
  • Contact your manager / supervisor to inform them of your screening results
  • Take a screenshot/picture of your result to send to your manager/supervisor if able
  • Contact OH&S Hotline at 1-833-233-4403 for further instructions
    • Based on your results, you need to be tested for Covid-19
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LONG TERM CARE TOOL
NOT PERMITTED TO WORK


Based on the answers to your Screening Assessment you need to continue to self isolate and you are NOT permitted to work

  • You are required to self-isolate until you receive further instructions
  • Contact your manager / supervisor to inform them of your screening results
  • Take a screenshot/picture of your result to send to your manager/supervisor if able
  • Contact OH&S Hotline at 1-833-233-4403 for further instructions
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Restart Assessment

LONG TERM CARE TOOL
NOT PERMITTED TO WORK


Based on the answers to your Screening Assessment you need to immediately self isolate and you are NOT permitted to work

  • You are required to self-isolate for 14 days
    • All travellers returning from international destinations are subject to a mandatory self-isolation order under the Public Health Order (March 20,2020). Violation of the order may result in a fine.
  • Contact your manager / supervisor to inform them of your screening results
  • Take a screenshot/picture of your result to send to your manager/supervisor if able
  • Contact OH&S Hotline at 1-833-233-4403 for further instructions
    • You do NOT need to be tested for Covid-19 as you do not have symptoms
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LONG TERM CARE TOOL
NOT PERMITTED TO WORK


Based on the answers to your Screening Assessment you need to mandatory self isolate and you are NOT permitted to work

  • You are required to self-isolate for 14 days
    • Anyone identified as a close contact of someone with COVID-19 shall go into mandatory self-isolation for 14 days from the date of having been exposed under the Public Health Order.
  • Contact your manager / supervisor to inform them of your screening results
  • Take a screenshot/picture of your result to send to your manager/supervisor if able
  • Contact OH&S Hotline at 1-833-233-4403 for further instructions
    • You do NOT need to be tested for Covid-19 as you do not have symptoms
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LONG TERM CARE TOOL
PERMITTED TO WORK – Self Monitor


Based on the answers to your Screening Assessment, you ARE permitted to work BUT need to self-monitor

  • You are required to self-monitor and maintain a physical distance while working and on breaks
  • If you are unable to maintain appropriate physical distance, you should mask even if not in clinical areas or zones
  • Self-monitoring includes temperature checks, pre and post shifts
  • Please take a screenshot/picture of this result and present it to the screening staff on arrival to your workplace if you are able.
  • Ensure you are always following hand hygiene protocols and cleaning your keys, phone, computer and other personal items.
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LONG TERM CARE TOOL
PERMITTED TO WORK – Self Monitor


Based on the answers to your Screening Assessment, you ARE permitted to work BUT need to self-monitor

  • You are required to self-monitor
    • If you have travelled, you are required to self-monitor 14 days from your return date
    • If you have had a non-close contact, you are required to self-monitor 14 days from your last exposure
  • Self-monitoring includes temperature checks, pre and post shifts
  • Please take a screenshot/picture of this result and present it to the screening staff on arrival to your workplace if you are able.
  • Ensure you are always following hand hygiene protocols and cleaning your keys, phone, computer and other personal items.
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LONG TERM CARE TOOL
PERMITTED TO WORK - Self Monitor


You ARE permitted to work BUT need to self-monitor

  • Please take a screenshot/picture of this result and present it to the screening staff on arrival to your workplace if you are able.
  • Ensure you are always following hand hygiene protocols and cleaning your keys, phone, computer and other personal items.
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Mandatory Self-Isolation
Please Call HealthLine 811.

Anyone identified as a close contact of someone with COVID-19 shall go into mandatory self-isolation for 14 days from the date of having been exposed under the Public Health Order (March 20, 2020). Violation of the order may result in a fine.

Based on the responses you've just provided, please call HealthLine 811 to have your symptoms assessed.

Please do not go to an emergency department, family doctor or walk-in clinic unless your symptoms worsen.

Visit https://www.saskatchewan.ca/coronavirus for more information

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Restart Assessment
Adapted from and with thanks to Alberta Health Services
Date Modified: 2 June, 2020
Adapted from and with thanks to Alberta Health Services
Date Modified: 2 June, 2020