Municipal Facility COVID-19 Self-Assessment Screening Tool

This COVID-19 Self-Assessment Screening Tool must be completed on the day of your planned meeting or event within a municipal building. Please read the questions carefully before answering. Complete all questions and submit your results. When you complete the assessment, an email will be sent to the email address you provide in the assessment. Proof of completing this assessment tool must be shown prior to entering the municipal facility for your meeting or event.

You are completing this assessment as a:

Which municipal location will you be attending?

Enter your first name

Enter your last name

Enter your email address:

Enter your phone number

For contact tracing purposes, please enter your arrival and departure times for your event as accurately as possible.

Arrival time:

Departure time:

Are you currently, or have you in the past 24 hours, been feeling unwell OR do you have any new unexplained symptoms related to COVID-19 such as:

Fever (feeling hot to the touch, a temperature of 37.8 degrees Celsius or higher)
Chills
Cough that's new or worsening (continuous, more than usual)
Barking cough, making a whistling noise when breathing (croup)
Shortness of breath (out of breath, unable to breathe deeply)
Sore throat
Difficulty swallowing
Runny nose (not related to seasonal allergies or other known causes or conditions)
Stuffy or congested nose (not related to seasonal allergies or other known causes or conditions)
Lost sense of taste or smell
Pink eye (conjunctivitis)
Headache that’s unusual or long lasting
Digestive issues (nausea/vomiting, diarrhea, stomach pain)
Muscle aches
Extreme tiredness that is unusual (fatigue, lack of energy)
Falling down often
For young children and infants: sluggishness or lack of appetite

Any symptoms to report from the list above?

Yes

Have you travelled outside of Northwestern Ontario (Manitoba border to Manitouwadge) in the last 14 days?

Yes

In the past 14 days, has a member of your household returned from travel outside of Northwestern Ontario and developed symptoms of COVID-19?

Yes

In the past 14 days, have you had close contact with a confirmed or probable case of COVID-19, as informed by the Thunder Bay District Health Unit or an exposure notification through the COVID Alert App?

Yes

Have you recently been tested for COVID-19 due to symptoms and are currently awaiting test results?

Yes

Have you answered all of these prescreening questions truthfully to the best of your knowledge?

Yes

Acknowledgements:

I understand that if I do not pass this screening tool I am not to enter the facility.

I understand that if I become ill or develop symptoms while in the facility, I should leave the facility immediately, self-isolate and contact Public Health for information regarding COVID-19 testing.

Any collection of personal information is made under the authority of the Ministry of Health COVID-19 Guidance for public facilities during COVID-19. Personal information is collected in compliance with the Municipal Freedom of Information and Protection of Privacy Act.

Personal information is collected for the purpose of complying with provincial orders related to the COVID-19 pandemic. None of your personal information will be shared, rented, sold or otherwise released to any third party without your consent.

Any questions about this collection should be directed to: 474-5331

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Municipal Facility COVID-19 Self-Assessment Screening Tool