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

Yes

Sore throat; difficulty swallowing; decrease or loss of smell or taste; runny/stuffy/congested nose (not due to allergies)

Yes

Head ache; pink eye; digestive issues like nausea/vomiting/diarrhea/stomach pain

Yes

Extreme tiredness; muscle ache

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 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?

Yes

In the last 14 days, have you received a COVID Alert exposure notification to your cell phone? (If you already went for a test and got a negative result, select "No."

Yes

In the last 14 days, have you or anyone you live with travelled outside of Canada? (If you or anyone you live with are exempted from federal quarantine as per Group Exemptions, Quarantine Requirements under the Quarantine Act, select “No”.)

Yes

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

Yes

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COVID-19 Visitor Screening Form