COVID-19 Visitor Screening Form

The safety of our employees, residents and visitors remain the Town of St. Marys’ overriding priority. As the COVID-19 outbreak continues to evolve, the Town is continually monitoring the situation closely and will periodically update our policies and procedures based on current recommendations from Huron Perth Public Health.

In doing our part to provide a safe and healthy workplace, we require all visitors to complete this screening form prior to entering our facilities. Your honest answers will help us keep everyone safe.

Collection of Personal Information

Personal information on this form is collected in accordance with the Municipal Freedom of Information and Protection of Privacy Act. It is to be used for the purpose of administering health and safety precautions within municipal facilities. Any questions regarding the collection, use and retention of personal information on this form can be directed to the Town of St. Marys Clerk (clerksoffice@town.stmarys.on.ca).

Full name

Company name (if applicable)

Phone number

Date

Time

Which municipal facility are you visiting?

Which department or employee initiated the reason for your visit?

Do you have any of the following new or worsening COVID-19 symptoms? (Symptoms should not be chronic or related to other known causes or conditions.)

Fever/chills; new cough or a cough that is getting worse; difficulty breathing or shortness of breath (even when sitting or walking regularly)

Yes

Sore throat or runny/congested nose (not due to allergies)

Yes

Unusual level of fatigue or headache; nausea/vomiting, diarrhea or loss of appetite

Yes

Feeling unwell for an unknown reason

Yes

In the last 14 days, have you been in close contact with a positive COVID-19 case, or been advised to self-isolate by public health?

Yes

Have you returned from travel outside Canada in the past 14 days?

Yes

If you answered YES to any of these questions, you are not permitted to enter this facility and should go home and self-isolate right away. Call your health care provider or Huron Perth Public Health's Health Line at 1-888-221-2133, ext. 3267 and a public health nurse will give you detailed instructions to follow to protect yourself, your family and members of the public.

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COVID-19 Visitor Screening Form