Covid 19 Screening

First Name *

Last Name *

Email *

Phone Number *

Name of program you are participating in - or meeting/training attending *

Date of program/meeting/training *

Are you completing this screening for others in your household? *

Yes

No

Names of others in your household (type NA if not applicable) *

Do you have any of the following symptoms? *

Does anyone in your immediate household have any of the above symptoms?

Yes

No

Exposure History (check all that apply): *

Have you or someone you live with travelled outside of Canada AND been advised to quarantine (as per federal quarantine requirements)?

Has a doctor, healthcare provider, or public health unit told you that you should currently be isolating (staying at home)?

In the last 5 days, have you been identified as a “close contact” of someone who currently has COVID-19?

In the last 5 days, have you tested positive on a rapid antigen test or a home-based self-testing kit?

In the last 5 days, have you received a COVID Alert exposure notification on your cell phone?

In the last 5 days, has someone you live with been identified as a “close contact” of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self-isolate?

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

None of the above

If you have checked any boxes other than "none of the above", or have checked "yes", do not come to the program/event or enter any Conservation Area. Go home, self-isolate and follow all public health guidelines.

Additional Information (use if needed):

Accuracy of Information *

I certify that the information provided above is accurate at this current time

Collection of Information *

I understand that information collected will be kept confidential and only used for contact tracing purposes.

Signature

Clear

Screening and Contact Tracing Information