COVID-19 Daily Screening and Vaccine Verification

Name*

First NameLast Name

Phone Number*

Email*

example@example.com

Room*

When responding to the below questions, please do not disclose any symptoms caused by a pre-existing and non-contagious health condition.

1. Have you received a confirmed diagnosis for coronavirus (COVID-19) by a coronavirus (COVID-19) test or from a diagnosis by a health care professional in the past 14 days?*

NOYES

2. Have you traveled internationally (any travel mode) in the last 14 days?*

NOYES

3. Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?*

NOYES

4. Have you experienced in the last 14 days at least 1 (one) of the following symptoms: Cough, Shortness of breath or difficulty breathing*

NOYES

5. Have you experienced in the last 14 days at least 2 (two) of the following symptoms: Fever, Chills, Repeated shaking with chills, Muscle pain, Headache, Sore throat and/or New loss of taste or smell*

NOYES

VISIT MAY ONLY BE AUTHORIZED WHEN THE RESPONSE TO ALL 5 QUESTIONS ABOVE IS "NO"

ACKNOWLEDGEMENT AND RELEASE

In consideration for being permitted onto CHSI’s premises, I represent and promise as follows:

1.    To the best of my knowledge, I am not presently infected with COVID-19. In the past 14 days, I have not experienced symptoms consistent with COVID-19 (except as may be associated with a pre-existing, non-contagious health condition), or been within 6 (six) feet of any person infected with COVID-19.

2.    While on CHSI’s premises, I will comply with all CHSI policies and procedures concerning COVID-19, as may be communicated to me from time to time in any manner.

3.    I understand that CHSI is collecting and will use the information submitted by me on this form solely for determining whether I will be permitted entry to CHSI’s premises. CHSI will not disclose or share this information with any third parties, except as follows:

a.    Where required by law, including (without limitation) if CHSI is required to report to public health authorities or any other governmental or regulatory authority; and/or

b. If I have a confirmed or probable/suspected case of COVID-19, to other individuals with whom I have been in contact at CHSI premises within the preceding 14 days, to the extent necessary or prudent for the purposes of protecting the health and safety of others and/or controlling the spread of COVID-19.

Access will be limited to authorized representatives of CHSI who have a need to know the information for the purposes described above. By submitting this form, I consent to the collection, use and storage of my personal information as described above. I understand that any questions about the collection of my personal information can be addressed to the Office Coordinator.

4. TO THE FULLEST EXTENT PERMITTED BY ONTARIO LAW, I KNOWINGLY AND VOLUNTARILY RELEASE AND COVENANT NOT TO SUE CHSI, ITS DIRECTORS, OFFICERS, AND/OR ITS EMPLOYEES FOR ANY COVID-19 RELATED CLAIMS ARISING OR ALLEGEDLY ARISING FROM ACCESS TO CHSI PREMISES.

Date*

Date

Signature*

COVID-19 DAILY SCREENING QUESTIONNAIRE