COVID SCREENING

Full Name

Phone

Email Address

Which Building are you visiting? Which Building are you visiting?148 Third St., Cobourg120 University Ave., Cobourg169 Division St., Cobourg1 Queen St., Cobourg841 Battell Crt., Cobourg869 Clonsilla Ave., Peterborough36 Champlain Cres., Peterborough494 Elgin St. West, Cobourg373 D'arcy St., Cobourg

Which unit will you visit?

Purpose of visit?

Date of your visit (MM/DD/YY)

In the last 14 days, have you travelled outside of Canada? In the last 14 days, have you travelled outside of Canada? Yes No

In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19? In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19? Yes No

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

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have. Fever and/or chills: Temperature of 37.8 degrees Celsius /100 degrees Fahrenheit or higher Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have. Fever and/or chills: Temperature of 37.8 degrees Celsius /100 degrees Fahrenheit or higher Yes No

Cough or barking cough: Continuous, more than usual, making whistling nose when breathing (not related to asthma, COPD or other known causes or conditions you already have Cough or barking cough: Continuous, more than usual, making whistling nose when breathing (not related to asthma, COPD or other known causes or conditions you already have Yes No

Shortness of breath: Being outof breath, unable to breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have) Shortness of breath: Being outof breath, unable to breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have) Yes No

Sore Throat: Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have Sore Throat: Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have Yes No

Runny or Stuffy/congested nose: Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have Runny or Stuffy/congested nose: Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have Yes No

Decrease or loss of taste or smell: Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have Decrease or loss of taste or smell: Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have Yes No

Pink eye: Conjunctivitis (not related to recurring styes or other known causes or conditions you already have) Pink eye: Conjunctivitis (not related to recurring styes or other known causes or conditions you already have) Yes No

Headache: Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have) Headache: Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have) Yes No

Digestive issues: Like nausea/vomitting, diarrhea, stomach pain. Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have) Digestive issues: Like nausea/vomitting, diarrhea, stomach pain. Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have) Yes No

Muscle aches: Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have Muscle aches: Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have Yes No

Extreme tiredness: Unusual, fatigue,lack of energy ( not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have Extreme tiredness: Unusual, fatigue,lack of energy ( not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have Yes No

DO NOT enter the building if you answered YES to any of the above. DO NOT enter the building if you answered YES to any of the above. My answers to the above are truthful/accurate I will advise the occupants of the unit I visited if I develop any of the above symptoms in the next 14 days or if I am diagnosed with COVID-19