Employee Covid-19 Health Declaration
Staff Member Name
Shift Date
Assigned Shift
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AM - Park
AM - Zoo
Close - Park
Close - Zoo
Roving Team
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1. Are you Sick?
Shortness of Breath
Chest Pain
Unconsciousness
Very Tired/Confused
Are you feeling any of these feelings?
YES? - Call 911 or go straight to Emergency Room
NO? - It is safe to go to work.
2. You hard to breathe lying down?
YES? - Call Health Links 204-788-8200 to talk about it
NO? - Still Safe to go to work.
3. Do you have any...
Are you feeling any of these feelings?
YES? - Stay home, Call Angela 204-996-3219
NO? - Still Safe to go to work.
4. Do People in your House Feel Sick?
People in your house feeling these feelings?
YES? - Stay home, Call Angela 204-996-3219
NO? - Still Safe to go to work.
5. Last 14 Days, did you;
Meet a person Travel out Manitoba? - Stay home, Call Angela 204-996-3219
Meet a personTravel out Canada? - - Stay home, Call Angela 204-996-3219
Meet a person Self Isolating? - - Stay home, Call Angela 204-996-3219
Meet a person with COVID-19? - - Stay home, Call Angela 204-996-3219
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