U7-1 COVID-19 APMHA Daily Screening
Please complete the below questionnaire prior to your participation in any APMHA activity and on the same day as the activity.

REMINDER – THIS FORM IS ONLY VALID IF COMPLETED ON THE DAY OF YOUR ACTIVITY.

A new form must be completed prior to each ACTIVITY, for each person entering the facility
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Email Address
Participant Name
Role*
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Facility
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Start Time
Zeit
:
Do you currently have any COVID-19 related symptoms? (fever, chills, cough, difficulty breathing, sore throat, runny nose, loss of taste/smell, diarrhea, nausea, vomiting, abdominal pain or nasal congestion) *
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In the last 14 days, have you had close physical contact with a person who was a confirmed or probable case of COVID-19? *
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In the last 14 days, have you attended an event or gathering (including sports tournament) other than those which are permitted under Ontario's current re-opening phase? If yes, you must refrain from participating in any APMHA activity until 14 days have passed symptom-free *
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By agreeing, I acknowledge that all information provided above is accurate and I have agreed to follow the policies and procedures put in place by APMHA and the facilities upon entering the building. *
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If you answered YES to any of the screening questions above, go home & self-isolate right away. Visit https://healthunit.org/coronavirus  for more information as you may be eligible for a COVID-19 test.
If feeling unwell, contact your health care provider or call Telehealth Ontario at 1-866-797-0000 to speak to a registered nurse or Leeds Grenville and Lanark District Health Unit at 1-800-660-5853 ex.2499
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