Covid Self-Screen

Please complete the following self-screen form prior to attending the worship service.

If you answered YES to any of these questions, go home & self-isolate. Call Telehealth or your health care provider to find out if you need a test. If you answered NO to all of these questions, you can attend your activity. The above questions are used to screen for COVID-19 before entry, as per direction from the Medical Officer of Health.

Phone

Email

Social Media

123-456-7890 

info@mysite.com

  • Facebook
  • Twitter
  • LinkedIn
  • Instagram
Do you have any of the following new or worsening symptoms or signs? Fever or chills, Cough, Difficulty breathing or shortness of breath, Sore throat or trouble swallowing
Do you have any of the following new or worsening symptoms or signs? Runny or stuffy nose, Decrease or loss of taste or smell, Nausea vomitting or diarrhea, Fatigue or headache
Have you had close contact with a confirmed or probable case of COVID-19 without wearing appropriate PPE?
Have you travelled outside of Canada in the past 14 days?
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
Have you been identified as a “close contact” of someone who currently has COVID-19 in the last 14 days?
Have you received a COVID Alert exposure notification on your cell phone in the last 14 days (and have not been tested or are not waiting for your result)?