Covid-19 (CoronaVirus) Questionnaire

Covid-19 (CoronaVirus) Questionnaire
To prevent the spread of COVID-19 and reduce the potential risk of exposure, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone on grounds. Thank you for your time. This questionnaire must be completed each day by staff and for guests on grounds over 15 minutes.
Date*

MonthDayYear
Date
Time Coming on Grounds

:HourMinutesAM/PM Option
Anticipated Time Leaving Grounds

:HourMinutesAM/PM Option
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1. Have you traveled outside Canada in the last 14 days?*

YesNo
2. Are you in close contact with a person who is sick with new respiratory symptoms or who recently traveled outside of Canada?*

YesNo
3. Has someone you are in close contact with tested positive for COVID-19 in the last 14 days?*

YesNo
4. Do you have any of these symptoms?*

Fever greater than 38CChillsNew or worsening cough (dry or productive)Shortness of breath/difficulty breathingDecrease/Loss of taste or smellNone of the above
5. Do you have two or more of the following?:*

Sore throatHeadacheExtreme FatigueRunny nose/nasal congestionMuscle aches/joint painGI symptoms (ie vomiting or diarrhea)None of the above
If you are coming on grounds in the same vehicle with people from your exclusive family circle and can answer these questions the same for each person, please list their names below. If there is any difference in their contact information or answers they must complete a separate form.
If you have answered no to all of the above you may proceed to camp as scheduled.If you have answered yes to any of questions 1 - 3 please do not come to camp. Self isolation and testing may be advised.If you have answered yes to any of question 4 or two of question 5 please check with your doctor before coming to camp as these may be typical
Signature*

Clear
Should be Empty: