Required fields are marked with asterisks (*)

General Public Screening Questionnaire

The Tri-Township Arena and the Tri-Township Arena Board is taking steps to protect the health and safety of their employees. Screening of all individuals, including our own employees, is a condition of being granted entry to this facility.

Name

Date

Phone Number

Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions.

Do you have a fever? (Temperature of 37.8 degrees Celsius or higher)

Yes

Cough or barking cough (croup), shortness of breath, or decrease or loss of smell or taste.

Yes

For adults > 18 years or older

Fatigue, lethargy, malaise and/or myalgias.

Yes

For youth < 18 years

Nausea, vomiting and/or diarrhea.

Yes

In the last 14 days, have you or anyone you live with travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?

Yes

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

Yes

In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?

Yes

In the last 10 days, have you received a COVID alert exposure notification on your cell phone?

Yes

In the last 10 days, have you tested positive on a rapid antigen test or a home based self-testing kit?

Yes

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

Yes