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COVID-19 Coronavirus - Health Risk Pre-Screening Questionnaire

To prevent the spread of novel coronavirus (COVID-19) in our community and reduce
the risk of exposure to our staff and visitors, we are conducting a simple screening
questionnaire. Your participation is required to help us take precautionary measures to
protect our employees, associates, and visitors from the risks of this virus.

If you answer "YES" to any of the questions below, you are not authorized to enter our facility.

Please contact your host by phone and make alternate arrangements for your business.

* denotes required field

I am an:
1. Are you presently showing any symptoms such as severe chest pain, feeling confused, lost consciousness, having a very hard time waking up and/or severe difficulty breathing?
2. Are you presently having flu‐like symptoms, such as fever, cough, difficulty breathing, muscle aches, fatigue, headache, sore throat or running nose?
3. Have you experienced any of the above symptoms within the last 14 days?
4. Have you received public health or medical advice to self‐isolate?
5. In the last 14 days have you traveled outside of Canada or to a high‐risk area for transmission of COVID‐19? (This provision does not apply to those excluded in the public health directives regarding those important to the movement of goods, such as truck drivers.)
6. Have you been exposed to anyone confirmed positive, quarantined or is being evaluated for COVID‐19? (“exposed” means being within 2 meters for period of 15 minutes or more)

Thanks for submitting!

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