COVID-19 Screening Tool
Before entering North Grenville Community Church, please complete the screening questions as below.  Your answers will be kept confidential and only shared with the Leeds, Grenville and Lanark District Health Unit upon their request.

The purpose of this screening tool is to comply with Ontario Regulation 364/20 as well as to assist public health in their contract tracing efforts.

This tool is for use by staff and contractors of North Grenville Community Church.
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Name *
Phone number *
Date of Entry *
MM
/
DD
/
YYYY
Business or Company Name (Optional)
Approximate Duration of Visit *
1. Do you have any of the following new or worsening symptoms or signs? (Symptoms should not be chronic or related to other known causes or conditions.) *
Yes
No
Fever or Chills
Difficulty breathing or shortness of breath
Cough
Sore throat, trouble swallowing
Runny nose/stuffy nose or nasal congestion
Decrease or loss of smell or taste
Nausea, vomiting, diarrhea, abdominal pain
Not feeling well, extreme tiredness, sore muscles
2. Have you traveled outside of Canada in the past 14 days? *
3. Have you had close contact with a confirmed or probable case of COVID-19?
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Results of Screening Questions:

• If you answer NO to all questions from 1 through 3, you have passed and can enter the Church.


• If you answer YES to any questions from 1 through 3, you have not passed and should be advised that they should not enter the Church. You  should go home to self-isolate immediately and contact your health care provider or Telehealth Ontario (1 866-797-0000)to find out if you need a COVID-19 test.
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