Beechwood North Covid-19 Screening Questionnaire: 2021

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2021 Beechwood North Pool Covid-19 Screening Questionnaire:
All staff and visitors must perform the Covid-19 screening form before entering the Beechwood North (BNHA) facility.

One adult member per household needs to complete the following Covid screening form for all family members for each day of use of the BNHA facility.

Please complete this form BEFORE you arrive at the BNHA facility. The BNHA staff will have your answers electronically in order to allow entry into the pool. A BNHA staff member will be confirming that all patrons entering the pool facility have completed the health screening form and answered "NONE OF THE ABOVE" to all of the questions.

The use of the BNHA facility is completely voluntary. In completing this form, you are acknowledging your answers are honest and helping contribute to the safety of the BNHA staff and community. Although the BNHA has taken measures to follow the COVID 19 protocols established by the Province of Ontario and the Municipality along with the Life Saving Society in order to keep our staff and members safe, by choosing to use the BNHA pool facility, you agree to follow the protocols and understand and accept the risks associated with use of the premises including the risk of being exposed to community transmission of the COVID 19 virus.

**If you answered “NONE OF THE ABOVE” to all questions, you may enjoy the BNHA facility!**
*Required

Name of all family members who will be attending the pool today. Please include your last name. *

Date *

YYYY

Approximate Time of arrival (if known) *

Time

Select all that are applicable: *

Is anyone you live with currently experiencing any new Covid-19 symptoms and or waiting for test results after experiencing symptoms?

In the last 14 days, has a public health unit identified someone in your family as a close contact of someone who currently has Covid-19?

Has a doctor, health care professional or public health unit told someone in your family that they should currently be isolating (staying at home)?

In the last 14 days, has anyone who lives in your household traveled outside of Canada?

In the last 14 days, have you or someone in your household, received a Covid Alert exposure notification on your cell phone? (If you/they already went for a test and got a negative result, you are able to use the facility.)

NONE OF THE ABOVE

Required

Are you or anyone in your family experiencing any of the following symptoms? (select all applicable) *

Fever and or chills – temperature of 37.8 degrees Celcius/ 100 degrees Fahrenheit or higher

Cough: new onset cough or worsening chronic cough

Shortness of breath

Difficulty breathing

Sore throat or difficulty swallowing/painful swallowing not related to other known causes or conditions

Runny or stuffy/congested nose, not related to other known causes or conditions (such as seasonal allergies, acid reflux)

Headache that’s unusual/long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)

Nausea, vomiting and or diarrhea, not related to other known causes or conditions

Extreme tiredness that is unusual, muscle aches or abdominal pain not related to other known causes or conditions

Decrease or loss of taste or smell

Pink eye (conjunctivitis)

NONE OF THE ABOVE

Required

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