Name(s):

Date

Phone Number

Time Entered

Email Address

Do you have any of the following new or worsening symptoms or signs? Fever and/or chills,Cough or barking cough,Shortness of breath,Decrease or loss of smell or taste,Sore throat or difficulty swallowing,Pink eye,Runny or stuffy/congested nose.

Yes

No

In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the Federal quarantine requirements? If you are an essential worker who crosses the Canada-US border regularly for work, select “No”.

Yes

No

In the last 14 days, has a public health unit identified you as a close contact of someone who currently has Covid-19?

Yes

No

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

Yes

No

In the last 14 days, have you received a Covid Alert exposure notification on your cell? If you already went for a test and got a negative result, select “No”.

Yes

No

City of Stratford Facility Entrance Required Screening

Notice of Collection

The information submitted within this form is collected under the authority of the Municipal Act, 2001 via the City of Stratford. Data collection inquiries should be directed to Mark Hackett, Manager of Recreation Facilities at 519-271-0250 extension 269.

By submitting I acknowledge that I consent to having my data collected under the authority of the Municipal Act.