COVID-19 Questionnaire

Name: Billings Bridge Animal Hospital
Address: 1220 Rooneys Lane, Ottawa, ON, K1H 7Y7
Telephone: 613-737-5007

BILLINGS BRIDGE ANIMAL HOSPITAL

(T) 613-737-5007

COVID-19 Screening Questionnaire

To be completed by ANY individual entering the practice. Screening should occur before or when a worker enters the practice at the beginning of their shift, and before a client or other visitor is permitted inside the practice.

A COVID-19 symptom screening checklist is posted on our front door. You must answer NO to all of the questions in order to enter. You may enter if there are no more than 3 clients in the waiting room.

Clients will be allowed to be present in the room with some of our veterinarians if they are vaccinated, symptom free, and have a normal body temperature. Only one client is allowed per pet in the appointment room.

Staff/Visitor Name*

Visitor Contact Number:*

1.Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.

Fever or chills*

Yes

Difficulty breathing or shortness of breath*

Yes

Cough*

Yes

Sore throat, trouble swallowing*

Yes

Runny nose/stuffy nose or nasal congestion*

Yes

Decrease or loss of smell or taste*

Yes

Nausea, vomiting, diarrhea, abdominal pain*

Yes

Not feeling well, extreme tiredness, sore muscles*

Yes

2.Have you travelled outside of Canada in the past 14 days?*

Yes

3.Have you had close contact with a confirmed or probable case of COVID-19?*

Yes

Signature

Date

Results of Screening Questions:

If the individual answers NO to all questions, they have passed and can enter the workplace.

If the individual answers YES to any question, they have not passed and should be advised that they should not enter the workplace (including any outdoor, or partially outdoor workplaces). They should go home to self-isolate and contact their healthcare provider or Telehealth Ontario (1-866-797-0000) to find out if they need a COVID-19 test.

Retain forms for 30 days from the date of completion, then shred to ensure the privacy of the signee.