Annex C COVID-19 Self-Assessment Questionnaire

Are you experiencing any of the following:

• Severe difficulty breathing
• Severe chest pain
• Having a very hard time waking up
• Feeling confused
• Losing consciousness

YES/NO

If you answer YES stop questionnaire: Call 911 or go directly to your nearest emergency department

Are you experiencing any of the following:

• Mild to moderate shortness of breath
• Inability to lie down because of difficulty breathing
• Chronic health conditions that you are having difficulty managing because of difficulty breathing

YES/NO

If you answer YES to any questions:

• You are at risk of COVID-19 and should self-isolate
• Immediately contact your Chain of Command to inform them you are considered at risk
• Your Chain of Command will provide you with further direction in conjunction with the Canadian Forces Health Services team
• While waiting for further instructions, maintain physical distance, cough or sneeze into your elbow, and continue to keep your chain of command informed If you are screening in advance of onward movement, immediately notify your Chain of Command and do not board any vehicle (incl. aircraft)

Are you experiencing any of the following:

• Fever
• Cough
• Sore Throat
• Runny nose
• Headache

YES/NO

Have you travelled to any countries outside of Canada (including the United States) within the last 14 days?

Travel includes passing through an airport outside of Canada.

YES/NO

Within the last 14 days did you provide care or have close contact with a symptomatic person known or suspected to have COVID-19?

A close contact is defined as a person who:

• Provided care for the individual without consistent or appropriate personal protective equipment; or
• Lived with or otherwise had close prolonged contact (within 2 meters) with the person while they were infectious; or
• Had direct contact with infectious bodily fluids of a person (e.g. coughed or sneezed on) while not wearing recommended personal protective equipment.

YES/NO

Have you have close contact with a person who travelled outside of Canada in the last 14 days who has become ill (fever, cough, sore throat, runny nose or headache)?

YES/NO