Hillel Ontario Health Screening & Prescreening

Health Screening & Prescreening

We would love to see you at Hillel, however, no event is more important than our collective health. To keep each other healthy during this time, please fill out the form below to take accountability.
Name *

First Name Last Name
Email *
example@example.com
I am a...

Staff Student Visitor/Speaker Community Member Vendor
Campus *
What brings to the loft? *

To Study To Socialize I am In-Between Classes Other
Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.
- Fever or chills
- Difficulty breathing or shortness of breath
- Cough
- Sore throat, trouble swallowing
- Runny nose/stuffy nose or nasal congestion
- Decrease or loss of smell or taste
- Nausea, vomiting, diarrhea, abdominal pain
- Not feeling well, extreme tiredness, sore muscles

If yes, please select the symptom(s) that you have: *

	YES	NO
Fever or chills
Difficulty breathing or shortness of breath
Cough
Sore throat, trouble swallowing
Runny nose/stuffy nose or nasal congestion
Decrease or loss of smell or taste
Nausea, vomiting, diarrhea, abdominal pain
Not feeling well, extreme tiredness, sore muscles

In the last 14 days have you travelled outside of Canada and been advised to quarantine per the federal quarantine requirements? *

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
By checking this box you agree that all the information above it true. The information you've provided will be used for Hillel Ontario's contact tracing during the 2020 COVID-19 pandemic. Anyone entering a Hillel space will be required to wear a mask throughout your stay. Please bring your own mask. We thank everyone for their cooperation during this time.
If you have answered yes to any of the questions above, we, unfortunately, have to ask you to refrain from entering the premises at this time.

If you have symptoms of COVID-19, you must stay home and self-isolate for 14 days after your symptoms started. After 14 days, you can stop isolating if you no longer have a fever and your symptoms have improved, but you should continue with physical distancing measures. If you are still unwell at 14 days, contact Telehealth or your health care provider.
Should be Empty: