Outdoor Learning and Play Screening Form

Outdoor Learning and Play Screening Form

Government regulations in Ontario now require all businesses and organizations to screen workers and essential visitors for COVID-19 before entry to the premises. To ensure Evergreen is compliant with these rules, and to protect the health and safety of all who attend the Evergreen Brick Works site, please take a moment to answer the following questions. You are required to complete this form before arrival, each and every time you visit on-site grounds. Please note that parents/guardians can fill this form on behalf of a child.
Date *

Month Day Year
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
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.
Fever and/or chills *

Yes No
Cough or barking cough (croup) *

Yes No
Shortness of breath *

Yes No
Decrease or loss of taste/smell *

Yes No
Sore throat or difficulty swallowing *

Yes No
Runny or stuffy/congested nose *

Yes No
Nausea/vomiting, diarrhea, stomach pain *

Yes No
Headache. If you received a COVID-19 vaccination in the last 48 hours and are experiencing a mild headache that only began after vaccination, select “No.” *

Yes No
Muscle aches or extreme tiredness. If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild aches or mild fatigue that only began after vaccination, select “No.” *

Yes No
In the past 14 days, have you and/or your child travelled or had a layover outside of Canada? *

Yes No
In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19? *

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
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? *

Yes No
Has a doctor, health care provider, or public health unit told you that you shouldcurrently be isolating (staying at home)? *

Yes No
Are you waiting on COVID-19 testing, or COVID-19 test results? *

Yes No
If you have answered yes to any of the above questions you should not attend in person to Evergreen Brick Works (or any Evergreen-related offsite activities).
I confirm that my answers to the above questions are accurate, and that in attending on site I am agreeing to abide by all required health and safety protocols. *

Confirm
A copy of Evergreen’s COVID-19 Guide: Protecting our Staff, Volunteers & the Evergreen Brick Works Community can be found here: https://www.evergreen.ca/covid-19-preparedness/protecting-our-staff-volunteers-and-the-evergreen-brick-works-community/
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