Visitor COVID-19 Screening Questionnaire

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PLEASE COMPLETE THIS ON THE SAME DAY YOU WILL BE IN ATTENDANCE IN ORDER FOR IT TO BE AN ACCURATE SCREENING.

If you answered NO to all questions below, you have passed and can enter Bethel Church.

If you answered YES to any questions below, you have not passed and should be advised that you should not enter Bethel Church (including any outdoor, or partially outdoor, places). You should go home to self-isolate immediately and contact your health care provider or Telehealth Ontario (1-866-797-0000) to find out if you need a COVID-19 test.

Please enter your First and Last Name *

Please enter the first and last name of all family members attending from your household.

Please enter your phone number *

Please select today's date *

YYYY

Do you have at least one of the following symptoms: fever, new onset of cough, or difficulty breathing? (Symptoms should not be chronic or related to other known causes or conditions.) *

Yes

Do you have at least two of the following symptoms: chills, muscle aches, fatigue, headache, sore throat, nasal congestion, lost sense of taste or smell, digestive issues (nausea/vomiting, diarrhea, stomach pain), OR for young children and infants: sluggishness or lack of appetite? (Symptoms should not be chronic or related to other known causes or conditions.) *

Yes

In the last 14 days, have you travelled outside of Canada AND been advised to quarantine? *

Yes

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

Yes

Clear selection

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 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

Clear selection

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

Yes

Clear selection

If you answered YES to any questions above, you should go home to self-isolate immediately and contact your health care provider or Telehealth Ontario (1-866-797-0000) to find out if you need a COVID-19 test. *

I acknowledge

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