Impact Hub Ottawa COVID-19 Health Declaration & Screening Form

Impact Hub Ottawa COVID-19 Health Declaration & Screening Form

Our top priority is our community's health and safety. With that in mind, we're counting on all members and guests to self-assess and complete this health check-in before entering the space. Please read and answer the following 6 questions carefully. Please note that you are required to fill out the Health Declaration & Screening Form before every visit to the Hub.
Name

First Name Last Name
Email Address *
example@example.com
Contact Number *
Landline or Mobile Number
Date of entry/visit to the Hub

Month Day Year

Have you or anyone you live with travelled outside of Canada within the last 14 days? *

Yes No
If you answered "Yes" to the previous question, have you received a recognized negative test (RAT or Molecular) prior to or after your arrival?

Yes No

Did you contract COVID-19 within the past 14 days? *

Yes No
Did you isolate for a minimum of 5 days from the onset of your first symptoms, as recommended by Canadian health authorities?

Yes No

Declaration and Data Privacy Consent Form:

By submitting this form, I declare that the information I have given is true, correct, and complete. I understand that failure to answer any question or giving a false answer can be penalized in accordance with the law. I also voluntarily and freely consent to the collection and sharing of the above personal information only with Impact Hub Ottawa Staff and Ottawa Public Health if necessary.

If you answered NO to questions 1-6 , you passed the screening and CAN enter Impact Hub Ottawa.

If you have not been isolated for the required period of time and/or if you are experiencing any CODID-19 related symptoms, and/or if you did not receive a negative test (RAT, Molecular or other...) you did not pass the screening and CANNOT enter Impact Hub Ottawa. Anyone who does not pass screening is advised to not enter the Hub and to self-isolate, ideally at home, and call your health care provider or Telehealth Ontario (1-866-797-0000) to get advice or an assessment, including if you need a COVID-19 test.

If any of your answers to these screening questions change during your visit to Impact Hub Ottawa, you should inform the Hub Team of the change and go home to self-isolate immediately and contact their health care provider or Telehealth Ontario (1-866-797-0000) to get advice or an assessment, including if they need a COVID-19 test.

After your visit to the Hub, if you develop symptoms related to COVID-19 or are exposed to someone who has been diagnosed or is experiencing any of the aforementioned symptoms, please contact hello@hubottawa.org and relay the following information:

- When you were last at Impact Hub Ottawa
- When your symptoms started
- if you have been tested.

While respecting your privacy, all those who used the space on the day(s) of your visit will be notified via email.
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