Visitor Screening Form COVID-19

The health and safety of the public and Township employees is important at the Township of North Dumfries. Each visitor is asked to complete this questionnaire regarding their current health before entering a Township facility. The Township's primary goal is to prevent the spread of the COVID-19 virus. Please submit this completed form to Township staff.

Visitor Name

Visitor Address

Visitor Phone Number

Date

Have you been advised by the Public Health Authority or your family physician to self-monitor or self-isolate in the last 14 days?

Yes

In the last 14 days, have you been in close contact with someone who currently has COVID-19 or is awaiting test results after experiencing symptoms?

Yes

In the last 14 days, have you received a COVID-19 Alert exposure notification on your cell phone?

Yes

Have you or anyone you lived with travelled outside of Canada in the last 14 days?

Yes

If you answered YES to travelling outside of Canada in the last 14 days, where did you go and what were the dates?

If any answer was "YES" or you are experiencing any of the above symptoms, please do not enter the Township facility. Contact Public Health and/or your health care practitioner immediately and seek guidance as to next steps.

Visitors are requested to remember:

If any individual develops flu-like symptoms, they must immediately leave the Township facility and self-isolate. Contact Public Health and/or your medical practitioner and seek guidance.
If you experience flu-like symptoms within 72 hours of your visit to the Township, you are requested to notify the Township office immediately.
In a Township facility or where physical distancing (2 metres) cannot be achieved, Visitors are to wear a non-medical mask. The Township will provide a face covering if you do not possess a mask.
At all times while in our facility, members of the Public and Staff are to maintain 2 metres (6 feet) apart.
Visitors are to wash their hands with soap & water. Where soap & water are not available, Visitors should use hand sanitizer.
Cough or sneeze into your sleeve.

Location of Visit

Purpose of Visit

Name(s) of Township Staff Requesting to Visit (if applicable)

Signature

Clear

A healthy and safe municipality is everyone’s responsibility. Your active participation and support are vitally important to maintaining and improving health and safety in Township facilities.