COVID-19

Visitor screening questionnaire

All visitors are now required to fill out this form before they are given entry. Please answer truthfully.

Visitor name

Purpose of visit

Phone number

Have you travelled outside of Canada in the last 14 days?

YesNo

Have you been in close contact with anyone who tested positive of COVID-19?

YesNo

Do you have any of the following symptions?

FeverNew onset of coughWorsening chronic coughDifficulty breathingSore throat or hoarse VoiceDifficulty swallowingDecrease or loss of sense of taste or smellHeadachesUnexplained fatigue or muscle achesAbdominal painNausea or vomitingPink eye (conjunctivitis)Runny noseNasal congestion without other known cause

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