USC COVID-19 Assessment

In support of Western’s commitment to Workplace Health and Safety and on the recommendation of the Middlesex London Health Unit, all staff members are asked to complete this questionnaire prior to each shift/visit to campus.

Completion of this questionnaire will help you to decide whether it’s safe for you to return to campus without potentially exposing others in the campus community to COVID-19. If you answer “yes” to any of the following questions, please do not come to campus until you have consulted with a health care practitioner.

Name Name First Last
Executive / Senior Manager
Operation
Are you currently experiencing any of these issues? Call 911 if you are.
- Severe difficulty breathing (struggling for each breath, can only speak in single words)
- Severe chest pain (constant tightness or crushing sensation)
- Feeling confused or unsure of where you are
- Losing consciousness

Are you currently experiencing any of these issues? Call 911 if you are.
- Severe difficulty breathing (struggling for each breath, can only speak in single words)
- Severe chest pain (constant tightness or crushing sensation)
- Feeling confused or unsure of where you are
- Losing consciousness No Yes
Are you currently experiencing any of these symptoms?
Choose any/all that apply.

Are you currently experiencing any of these symptoms?
Choose any/all that apply. Fever (feeling hot to the touch, a temperature of 37.8 degrees Celsius or higher) Chills Cough that's new or worsening (continuous, more than usual) Barking cough, making a whistling noise when breathing (croup) Shortness of breath (out of breath, unable to breathe deeply) Lost sense of taste or smell Muscle aches Extreme tiredness that is unusual (fatigue, lack of energy) None of the above
Have you travelled outside of Canada in the last 14 days, and been required to quarantine per federal regulations?

Have you travelled outside of Canada in the last 14 days, and been required to quarantine per federal regulations? No Yes
In the last 14 days, have you been in close physical contact with someone who either:
- tested positive for COVID-19, or
- is currently sick with a new cough, fever, or difficulty breathing.
(Close physical contact means being less than 2 meters away in the same room, workspace or area for over 15 minutes.)

In the last 14 days, have you been in close physical contact with someone who either:
- tested positive for COVID-19, or
- is currently sick with a new cough, fever, or difficulty breathing.
(Close physical contact means being less than 2 meters away in the same room, workspace or area for over 15 minutes.) No Yes