United Way Windsor-Essex Outside Visitor COVID-19 Self-Assessment

The following COVID-19 self-assessment must be completed prior to entering the office or an off-site location for each individual office or off-site visit. Completing this self-assessment is mandatory, and self-assessments will be cross-referenced with those accessing the office to ensure compliance. The self-assessment process is in place to ensure the utmost safety of United Way staff, students, volunteers, and partners. Please contact the staff member facilitating your visit to our office if you have any questions or concerns.

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* 1. Please enter your first and last name.

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* 2. Please provide your phone number (we will only contact you in the event that you may have been exposed to COVID-19).

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* 3. Please select the name of the staff member who is facilitating your access to the United Way office or off-site location.

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* 4. Please indicate whether you will be accessing the office and/or an off-site location.

Office

Off-site location(s)

If off-site, please indicate the name of the location(s) you'll be accessing.

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* 5. Please select the date/time.

Date / Time

Date

Time

AM/PM

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* 6. Are you currently experiencing any of these symptoms?

Fever and/or chills (temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher)

Cough or barking cough (continuous, more than usual, making a whistling noise when breathing)

Shortness of breath (out of breath, unable to breathe deeply)

Decreased or lost sense of taste or smell

Muscle aches/joint pain (unusual or long lasting - not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have)

Extreme tiredness (unusual, fatigue, lack of energy - not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

None of the above

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* 7. In the last 5 days, have you been identified as a “close contact” of someone who currently has COVID-19?

Yes

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* 8. In the last 5 days, have you been in close physical contact with someone who is currently sick with new COVID-19 symptoms (like a cough, fever, or difficulty breathing)?

Yes