Influenza/(H1N1 – Swine Flu) Employee Self Assessment and ECM Referral Form This form has been prepared for the use of the employees (working in Canada or the United States) of the companies for whom The ECM Group is providing Occupational Health and Disability Management services. Please complete all applicable information and submit the form to ECM if you have Influenza symptoms (outlined in Question #3) or would like a nurse from The ECM Group to call you. You can also contact The ECM Group by telephone during business hours at 1-800-472-4904. The purpose of this form is to provide information on Influenza/H1N1 and to provide access to The ECM Group’s health professionals for an initial assessment, enabling you to have your health concerns addressed. The medical information you provide to ECM on this form is confidential and will not be released to a third party without your consent, however the workplace will be notified of your fitness to work. Employer * Employee Name * Phone Number where the ECM Nurse can Contact You* Employee Email Address Work Location* Supervisor/Manager Name Supervisor/Manager Phone Number Supervisor/Manager Email Address Please Answer All Of The Questions Below That May Pertain To You 1. I am not ill but need information about Influenza or the Vaccine: .... Yes No 2. I feel well but I have a close family member, live with a person, or have been in close contact with a person who I believe may have Influenza/H1N1 (Swine Flu) – should I go to work? .... Does Not Apply To Me Applies to Me (See Answer Below) Answer: If you do not have symptoms of Influenza (outlined below) you can continue to work. As you may have been exposed to someone with Influenza symptoms and therefore may become infectious a day before you become ill, it is important that you take precautions to protect others from infection (i.e. hand washing and cough etiquette). Refer to the website below for more information. a) Preventing infection in yourself and others: Canada: http://www.health.alberta.ca/health-info/Influenza-H1N1.html United States: http://www.cdc.gov/h1n1flu/qa.htm b) Taking care of someone ill with Influenza: Canada: http://www.health.alberta.ca/health-info/Influenza-self-care.html United States: http://www.cdc.gov/h1n1flu/guidance_homecare.htm 3. I feel well but I am planning to travel internationally or I have just returned from international travel – is there anything I need to do? .... Does Not Apply To Me Applies to Me (See Answer Below) Answer: a) If you are planning to travel internationally for work related reasons please submit this form or call The ECM Group to ensure you receive appropriate information and any preventative vaccines or medications that may be required. b) If you plan to travel for personal reasons refer to the following website for information: Canada: http://www.phac-aspc.gc.ca/tmp-pmv/2009/h1n1_global-090722-eng.php United States: http://wwwn.cdc.gov/travel/content/novel-h1n1-flu.aspx c) If you have returned from travel and have Influenza symptoms complete the questions in # 3 below and submit this form to ECM for follow up. d) If you have returned from travel and have no Influenza symptoms you can return to work but take steps to prevent infection outlined in 1(a) above. 4. I currently have symptoms that I believe may be that of Influenza or H1N1 (Swine Flu). Please answer the following questions to determine if your symptoms are like that of the Common Cold or of Influenza. Check all that apply to you. Common Cold: No Fever - mild fever sometimes may occur Coughing - sometimes Headache - rarely occurs - less severe Muscle Aches & Pains - rare or mild Fatigue - nil to mild Sore throat Sneezing - usually Runny Nose - usually Nausea, Vomiting Diarrhea - rarely occurs Influenza/H1N1: Fever - usually high beginning suddenly Coughing - usually Headache - can be sudden and severe Muscle Aches & Pains - more severe Fatigue - extreme tiredness Sore throat - may be more severe Sneezing - sometimes occurs Runny Nose - sometimes occurs Nausea, Vomiting Diarrhea - sometimes occurs a) If you do not have a fever and your symptoms are mostly that of the common cold and you are not feeling significantly unwell, you should be able to continue to work. It is important that you manage your symptoms so as not to infect others. Refer to the following link for information on symptom management. Canada: http://www.health.alberta.ca/health-info/Influenza-H1N1.html United States: http://www.cdc.gov/h1n1flu/qa.htm#d b) If you have a fever and Influenza like symptoms stay at home. Do not go into work. Answer the questions below and submit this form to the ECM Group for further follow up and notify your supervisor of your work absence. Do you have any of the additional symptoms? Shortness of breath, either during physical activity or while resting Difficulty in breathing Turning blue (lips, nail-beds) Bloody or coloured (green) sputum Chest pain Altered Mental Status High fever that persists beyond 3 days Low Blood Pressure Yes   No Do any of the following conditions on the right apply to you? Pregnancy Asthma COPD, Emphysema or other respiratory disease Diabetes Mellitus Cardiac Disease Chronic Metabolic Disease Liver Disease Disease of the Blood or Immune system Impaired Immunity HIV Infection Chronic Neurological Disorders Yes   No I’m not sick, I have questions about influcenza/H1N1 vaccinations. Yes (I only have a question)   No (I am sick) If your symptoms are severe or worsen or you have medical conditions as outlined above, immediately contact your local Public Health resource (Alberta: HealthLink @ 1-866-408-5465 0R Edmonton 780-408-5465 OR Calgary 403-943-5465) OR call your Family Physician as you may require medical treatment or medication that must be given as early as possible to be effective; as well please submit this form to ECM for follow up. Once you have submitted this form, a nurse from The ECM Group will be in contact with you to discuss your situation, assist you where possible and to assess your ability to return to work. If you have not received a call from a nurse within one working day please call The ECM Group at 1-800-472-4904 OR Edmonton 780-413-1624 OR Calgary at 403-216-6120.       If printing, Fax Form To: ECM Calgary @ 403-216-6121 OR ECM Edmonton @ 780-413-6795