IHCCO Programs COVID-19 Screening

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EVERY PERSON, including children, attending or volunteering at the IHCCO programs needs to fill out this form every time before making a visit to Community Cultural Centre (aka Khane Farhangi Ma).

Please read the following questions carefully and answer them within 2 hours before you arrive at the venue.
A legal guardian of the child can fill out this form on behalf of him/her by asking the questions from the child or observing the child's conditions, and should brief the child with the health guidelines instructed at the end of this form. In this case, "you" refers to the child throughout the questionnaire.

Last updated: August 2021

Your Name (Last Name, First Name) *

Contact Number *

Have you failed to take the second shot of the COVID-19 vaccination? *

Yes

I'm under 12

Are you experiencing any of these symptoms that are new, worsening and not related to a chronic condition (such as asthma) or a disease-free cause (such as pregnancy)? *

1) Fever and/or chills (37.8°C/100.0°F or higher), 2) Cough, 3) Shortness of breath, 4) Decrease or loss of taste or smell, 5) Sore throat or difficulty swallowing, 6) Runny or stuffy/congested nose, 7) Nausea, vomiting and/or diarrhea, 8) Headache, 9) Extreme tiredness or muscle aches

Yes

Have you taken fever reducing medications in the last 5 hours? *

Yes

Have you been in close contact at home or in the community with someone who has been SYMPTOMATIC in the last 14 days? If the contact already went for a test and got a negative result, select “No”. *

Yes

Have you been in close contact at home or in the community with someone who has tested positive for COVID-19 in the past 14 days? *

Yes

Have you travelled internationally (outside of Canada) or been in close contact with someone who has within the past 14 days? If exempt from federal quarantine requirements, select "No". *

Yes

Has a doctor, health care provider, or public health unit told you that you should currently be isolating or staying at home? (This can be because of an outbreak or contact tracing.) *

Yes

Verification

If you have answered "Yes" to any of the above questions, we kindly ask you to avoid attending today's Muharram program and follow the Ottawa Public Health's instructions.

I confirm that during my visit to the IHCCO program, I will: *

Wear a mask that covers my mouth, nose and chin at all times except when eating (excluding children under 5 years of age and individuals with medical conditions)

Maintain physical distancing of at least 2 meters with individuals outside of my household, when possible

Perform hand hygiene when entering and leaving the premises

Follow the instructions of the organizers to manage the entry and exit points

Required

Acknowledgement and Assumption of Risks *

IHCCO has made every effort to ensure the safety of attendees, volunteers, and organizers by following the guidelines issued by Ottawa Public Health and Provincial Orders. However, we are still living in the pandemic era and there are risks of virus transmission, which I accept by attending the program. I have filled out this form with the best of my knowledge and take extra precautions when attending the program to help in keeping the venue safe for everyone.

I accept and acknowledge

Required

Legal Guardian's Name (Last Name, First Name)

If the form is filled out by a legal guardian on behalf of the child

Submit

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