GPCSD Visitor Self-Screening Questionnaire
ALL visitors, parents, I.T staff and maintenance staff are required to complete the following form prior to entering a GPCSD Facility.

This tool has been developed to support activity organizers and facility operators in reducing the risk of transmission of COVID-19 among attendees. The tool is meant to be used to assist with assessing attendees who may be symptomatic, or who may have been exposed to someone who is ill or has confirmed COVID-19.

Attendees should fill out this checklist prior to participating in the activity or program. If an individual answers YES to any of the questions, they are not be allowed to enter the building. Please self-isolate and call 811 for assistance.


As the COVID-19 pandemic continues to evolve, this screening tool will be updated as required.

Please submit a form each time you enter the facility.
Full Name *
Email *
Cell Phone Number *
What GPCSD facility are you entering? *
Do you / your child have any new onset (or worsening) of any of the following symptoms: *
YES
NO
Fever
Cough
Shortness of Breath / Difficulty Breathing
Sore throat
Chills
Painful swallowing
Runny Nose / Nasal Congestion
Feeling unwell / Fatigued
Nausea / Vomiting / Diarrhea
Unexplained loss of appetite
Loss of sense of taste or smell
Muscle/ Joint aches
Headache
Conjunctivitis (commonly known as pink eye)
Descriptions
* Face-to-face contact within 2 metres. A health care worker in a occupational setting wearing the recommended personal protective equipment is not considered to be a close contact.
** “ill/symptomatic” means someone with COVID-19 symptoms on the list above.
Has the attendee traveled outside of Canada in the last 14 days? *
Has the attendee had close contact* with a confirmed case of COVID-19 in the last 14 days? *
Has the attendee had close contact with a symptomatic** close contact of a confirmed case of COVID-19 in the last 14 days? *
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