Daily Pre-Entry COVID-19 Screening

If you cannot complete this screening assessment prior to your arrival at the facility, you must complete it immediately upon arrival and refrain from contact with anyone and common spaces until the screening is completed.

Date of Screening

Name (First and Last)

Please provide your email (to receive a confirmation of screening)

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have. If you have none of these symptoms, please select the NONE OF THE ABOVE option.

Fever and/or Chills

Couth or barking cough

Decrease or loss of smell or taste

Digestive issues like nausea/vomiting, diarrhea, stomach pain

Muscle aches

Extreme tiredness

NONE OF THE ABOVE

In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?

Yes

No

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

Yes

No

In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?

Yes

No

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

Yes

No

Form Builder