Villa Italia Visitor Checklist/Declaration Form


Read/Re-Read the following documents:

-The home’s visitor policy: https://bit.ly/2ILqZQm
-Public Health Ontario’s document entitled Recommended Steps: Putting on Personal Protective Equipment (PPE) https://www.publichealthontario.ca/-/media/documents/ncov/ipac/ppe-recommended-steps.pdf?la=en
 
Watched/Re-watched the following Public Health Ontario videos:

-Putting on Full Personal Protective Equipment: https://youtu.be/s2z1uM1fXN8
-Taking off Full Personal Protective Equipment: https://youtu.be/pFJaU9nxmTA
-How to Hand Wash: https://youtu.be/sDUJ4CAYhpA
Sign in to Google to save your progress. Learn more
Have you read the above description which includes the necessary forms and videos you must review prior to your visit? *
Have you booked a visit online or by calling 289 408 9975 and leaving a message? Visits of 30 minutes in duration will be strictly adhered to. *
Required
Have you reviewed Visitor Protocols and Respiratory Etiquette documents prior to coming into Villa Italia Retirement Residence?  Villa Italia Protocols https://bit.ly/2ILqZQm Respiratory Etiquette: https://bit.ly/RespiratoryEtiquette *
There is only two visitors allowed during the visit. *
Required
Will you bring a clean LEVEL1 surgical/procedure mask? Masks will not be provided by Villa Italia Retirement Residence. *
Required
Arrive 15 minutes early to check in for screening and protocol review? Your temperature will also be taken during screening. If you are late for your visit, your time will be reduced as such. a. Clean hands using sanitizer provided b. Hit speaker on phone in vestibule area. c. Dial 400 *
Required
No food or drinks are permitted in the visitation area during your visit. *
Required
Any packages must be left at reception for disinfecting purposes. After you leave, the package will be delivered to your loved one. *
Required
You must pass screening to proceed to your visit. Anyone that fails screening will not be permitted in the building. *
Required
Staff will escort you into the building and to the visitation area. Your loved one will be waiting for you in the visitation area. *
Required
You may not visit other residents during your visit. If you wish to visit another resident, a separate visit must be scheduled. *
Required
Physical distancing will be maintained in visitation area with a plexiglass screen. *
Required
Visitation area also will have video surveillance to ensure that physical distancing and proper use of mask is adhered to. *
Required
A warning bell will be sounded when there is 5 minutes remaining in your visit. *
Required
Will you ensure proper respiratory etiquette is followed during your visit. *
Required
At the end of your 30 minute visit, staff will escort you to exit the building. You must exit the building immediately. Please do not loiter to speak to other residents and staff. *
Required
You are not to wander throughout the building. *
Bathrooms will not be available to visitors. *
Required
Hands must be sanitized at entry and exit of the building. *
Required
Acknowledgement and Declaration of Understanding *
1.This confirms that I have read and understood the Policy and Procedures on Managing Resident & Visitor Visiting Protocols. 2.This confirms that I have read, understood and checked the Visitor Protocols and Requirements as outlined in this Checklist.   3. This confirms that I understand that I will follow all staff direction before and during my visit and failure to comply will result in discontinuation of visits.
What is your name? *
What is the name of the resident you are visiting? *
What is the room number of the resident you are visiting? *
What is the date of your visit? *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms