COVID-19 Screening Form

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This form is to ensure we are complying with safety regulations regarding the Coronavirus Pandemic.

Please fill out one form per person no longer than 12 hours prior to entering the facility for each visit.

Thanks for helping us keep our Shining Stars Community Safe!

Email *

Full Name *

Please select which best applies *

Are you feeling sick and have any of the following symptoms? (Please check all that apply. If you have 2 or more symptoms please stay home. If none apply, please check none of the above.) *

Cough

Headache

Weakness

Fever

Difficulty Breathing

Fatigue

Vomiting

Trouble Swollowing

Runny Nose

Loss of Taste or Smell

Chest Pain or Pressure

NONE OF THE ABOVE

Required

Have you travelled outside Canada in the past 14 days?   *

Yes

Did you provide care or have close contact with a person with COVID-19 (probable or confirmed) while they were ill and you did not have appropriate PPE?  *

Yes

Date Filled Out *

YYYY

Time Filled Out *

Time

Authorizing Person's Full Name *

An Authorizing person is anyone 18 years of age or older that is speaking for themselves, or are speaking as a parent/guardian for their child younger than 18 years of age. By providing us with your full name, you authorize that all of the above information is true.

A copy of your responses will be emailed to the address you provided.

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