Covid-19 Self Assessment Tool
Please complete the following form each time before coming into The Gate Alliance Church. (Updated 01/06/22)
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Name *
Date *
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YYYY
• If you are fully vaccinated, use 5 days
• If you are not fully vaccinated OR if you are immune compromised, use 10 days
*Symptons include:
Fever / chills, / New cough or a cough that is getting worse / Loss of taste or smell / Shortness of breath (while sitting or walking at a regular pace) / Sore throat /Runny nose / nasal congestion / Unusual level of fatigue / Unusual headache / Nausea / vomiting, diarrhea, or loss of appetite / Feeling unwell for an unknown reason
In the last [5, 10] days have you experienced any of these *symptoms? Anyone who is sick or has any new or worsening symptoms of illness, including those not listed above, should stay home until their symptoms are improving for 24 hours and should seek assessment from their health care provider if needed. Household members of individuals with any of the below symptoms should stay home at the same time as the person who is sick, regardless of vaccination status. *
In the last [5, 10]days have you tested positive for COVID-19? This includes a positive COVID-19 test result on a lab-based PCR test, rapid antigen test or home-based self-testing kit. *
Do any of the following apply? •You live with someone who is currently isolating because of a positive COVID-19 test •You live with someone who is currently isolating because of COVID-19 symptoms •You live with someone who is waiting for COVID-19 test results *
Have you been identified as a “close contact” of someone who currently has COVID-19 and been advised to self-isolate? *
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *
Do any of the following apply? •In the last 14 days, have you travelled outside of Canada and were told to quarantine •In the last 14 days, have you travelled outside of Canada and were told to not attend school/child care •In the last 14 days, someone you live with has returned from travelling outside of Canada and is isolating while awaiting results of a COVID-19 test. *
If you answered YES to any of the questions above, go home (stay home), consult your health care provider if you have or begin to develop symptoms.  Do not proceed to enter The Gate Campus.
Complete the OFFICIAL COVID-19 ASSESSMENT provided by Ontario Health: https://covid-19.ontario.ca/covid19-cms-assets/2022-01/COVID_screening_Staffs_Visitors_Jan6_AODA_0.pdf
COVD-19 Info-Line
905-688-8248 press 7 Toll-free: 1-888-505-6074
niagararegion.ca/COVID19
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