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 *

Month Day Year
Date
Time Coming on Grounds

: Hour Minutes AM/PM Option
Time Leaving Grounds

: Hour Minutes AM/PM Option
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

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

Yes No
2. Are you in close contact with a person who is sick with new respiratorysymptoms or who recently traveled outside of Canada? *

Yes No
3. Has someone you are in close contact with tested positive for COVID-19in the last 14 days? *

Yes No
4a. Do you have a fever greater than 37.7C? (Include recorded temperature) *

Yes No
5. Do you have any of these symptoms? *

Chills New or worsening cough (dry or productive) Shortness of breath/difficulty breathing Sore throat Difficulty swallowing Loss of taste or smell Nausea/vomiting, diarrhea, abdominal pain Runny nose or nasal congestion (aside from seasonal allergies) Pneumonia Barking cough (croup) Pink eye Headache that is unusual or long lasting Muscle aches Unexplained fatigue/malaise Falling more than usual 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 - 4 please do not come to camp. Self isolation and testing may be advised.If you have answered yes to any of question 5 please check with your doctor before coming to camp as these may be typical
Signature *

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Should be Empty: