Required fields are marked with asterisks (*)

Daily Pre-Entry COVID-19 Screening

Please complete this screening prior to arriving at the facility.

If you cannot complete this screening assessment prior to your arrival at the facility, you must complete it immediately upon arrival and refrain from contact with anyone and common spaces until the screening is completed.

Date of Visit (screening must be completed on the day of entry)

Name (First and Last) of Visitor

Please provide your email (to receive a confirmation of screening):

Facility

Municipal Town Hall

South Huron Recreation Centre (Arena)

South Huron Recreation Centre (Hall)

Stephen Township Arena

Expected time of arrival at the facility

COVID Symptoms (1 symptom)

Fever or chills
Cough
Shortness of breath
Decrease or loss of taste or smell

COVID Symptoms (combination of 2 or more symptoms)

Runny nose or nasal congestion
Headache
Extreme fatigue
Sore throat
Muscle aches or joint pain
Gastrointestinal symptoms (such as vomiting or diarrhea)

Are you currently experiencing any one (1) symptom OR a combination of two (2) of the symptoms listed above?

Yes

COVID Related Questions:

In the last 10 days, has someone you live with and/or tested positive for COVID-19 (on a rapid antigen test or PCR test or been sick with symptoms associated with COVID-19?
In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit?
In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?
In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19 (confirmed by a PCR or rapid antigen test)? If public health has advised you that you do not need to self-isolate, select “No.”
In the last 14 days, have you travelled outside of Canada? If exempt from federal quarantine requirements as directed by the border agent at your point of entry, select “No.”

Do any of the screening questions listed above apply to you? (by answering YES)

Yes

The Municipality of South Huron is committed to protecting the private information of our clients. The information entered on this form is collected under authority of the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA). This information will only be used for screening to keep our staff and visitors safe from the transmission of COVID-19.

Contact(s)