Covid-19 Screening Tool - Staff/Volunteers
Please complete the following form each time before coming into the Church.
Name *
Date *
MM
/
DD
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YYYY
*Symptons include:
Fever / chills, / New cough or a cough that is getting worse / Loss of taste or smell / Shortness of breath (while sitting or walking at a regular pace) / Sore throat /Runny nose / nasal congestion / Unusual level of fatigue / Unusual headache / Nausea / vomiting, diarrhea, or loss of appetite / Feeling unwell for an unknown reason
In the past 24 hours, have you experienced any *symptoms, not due to previously known chronic conditions diagnosed by a health care professional? *
In the past 24 hours, has anyone in your household (other than yourself) experienced any *symptoms, not due to a previously known chronic condition diagnosed by a health care professional and has not received a negative COVID-19 test result with respect to those symptoms? *
In the past 14 days, have you been in close contact with someone who has *symptoms of COVID-19, and 1) has travelled to a more heavily affected area of Canada 14 days prior to symptoms appearing or 2) had close contact with a confirmed case of COVID-19 or 3) has lived in or worked in a place with a confirmed outbreak of COVID-19 or 4) has been tested and results are unknown, and has not been told they can come out of isolation? *
In the past 14 days, were you or someone you live with 1) advised to consult with a heath care professional about COVID 19, but chose not to do so, or 2) advised to get tested for COVID-19, but chose not to do so, or 3) tested for COVID-19 due to *symptoms, but have not yet received the result? *
Have you returned from travel outside Canada in the past 14 days?(This does not include essential service workers who cross the borderregularly for the purpose of performing an essential job or function asper the Order issued under the Quarantine Act). *
If you answered YES to any of the questions above, go home, self-isolate right away, and call your health care provider if you have or begin to develop symptoms. Do not proceed to enter The Gate Campus.
COVD-19 Info-Line
905-688-8248 press 7 Toll-free: 1-888-505-6074
niagararegion.ca/COVID19
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