Client/Visitor Screening Form
French

Please select organization

Please select applicable province or territory

Please select applicable office

Who is answering the screening questions?

Screening Option


1. In the last 10 days, have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 (including being notified by the COVID-19 alert app) without wearing appropriate personal protective equipment (PPE - mask/face shield)?

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

3. Have you traveled outside of Canada in the past 14 days?


4. Do you have any of the following symptoms: fever, new onset of cough, worsening chronic cough, shortness of breath, difficulty breathing, sore throat, difficulty swallowing, decrease or loss of sense of taste or smell, chills, headaches, unexplained fatigue/muscle aches, nausea/vomiting, diarrhea, abdominal pain, pink eye (conjunctivitis), runny nose, nasal congestion without known cause?


5. If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium/confusion, unexplained or increased number of falls, difficulty doing normal tasks/increased functional decline, or worsening of chronic conditions?