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 and Phone Number (mandatory for contact tracing purposes)

Date

Have you 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?

Are you currently experiencing any of the following new symptoms?

Fever

Cough

Sore Throat

Difficulty swallowing

Difficulty breathing or shortness of breath

New olfactory or taste disorder(s)

Nausea/vomiting, diarrhea, abdominal pain

Runny nose or nasal congestion

No symptoms

If you answered yes, but do not think the symptoms are related to COVID-19, please explain your symptoms below.

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

Have you been in contact with someone who has made you aware they tested positive for COVID-19 or been in contact with a person who tested positive for COVID-19 within the past 14 days?

Yes

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

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

Purpose of Visit

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.