St. Andrew's Survey for Entrance to the Facilities - COVID-19 Self-Assessment
This survey must be completed before passing further into the church facilities.
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Date *
MM
/
DD
/
YYYY
Name *
Phone Number *
Numbers Only
Do you have any of the following symptoms? *
No
Yes
Diarrhea
Nausea or vomiting
New loss of taste or smell
Atypical headache
Unusual muscle or body aches
Flu like symptoms (headache, sore throat, runny nose)
New or worsening difficulty breathing (shortness of breath
New or worsening cough
Fatigue
Fever or chills
Have you travelled outside of Canada in the last 14 days? *
Have you been in contact with someone who has confirmed case of COVID-19 in the last 14 days? *
Have you been advised by your physician or a Public Health professional to be in self-isolation (currently or within the last 14 days)? *
If you are filling this survey out at home and you have checked "Yes" to any of these questions, please stay home and contact TeleHealth Ontario (1-866-797-0000) or your healthcare provider for advice on next steps.  Thank you.
If you are filling this survey out at church today and you have checked "Yes" to any of these questions, please do not attend the service today.  Rather go home and contact TeleHealth Ontario (1-866-797-0000) or your healthcare provider for advice on next steps.  Thank you.
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