Required fields are marked with asterisks (*)

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.

If you are experiencing ANY ONE OR MORE symptoms, do not enter the facility. Please follow the instructions indicated below.

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?

What is your age?

Under 18 years

18 years or older

Are you currently experiencing any ONE OR MORE of the following symptoms that are new or worsening? Symptoms should not be chronic or related to other know causes or conditions.

Fever and/or chills; cough or barking cough; shortness of breath; decrease or loss of smell or taste (Not related to any known causes or conditions you already have).

Yes

In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements).

Yes

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

Yes

In the last 10 days, have you been identified as a "close contact" of someone who currently has COVID-19? If public health has advised you that you do not need to self-isolate, select “No.”

Yes

In the last 10 days, have you received a COVID Alert exposure notification? (If you already went for a test and got a negative result, are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No.")

Yes

In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? If you have since tested negative on a lab-based PCR test, select “No".

Yes

In the last 14 days, has someone in your household (someone you live with) travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements) in the last 14 days?

Yes

In the last 10 days, has someone in your household (someone you live with) been identified as a ”close contact” of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self-isolate in the last 10 days?

Yes

Does anyone you live with have new COVID-19 symptoms and/or waiting for test results? If they received a vaccination in the last 48 hrs and have mild fatigue, muscle aches, and/or joint pain that began after or if you are fully immunized, select "No".

Yes

FormBuilder

COVID-19 Visitor Screening Form