COVID-19 Screening Form
In order for us to see you at church, you are required to complete this form no sooner than the morning of your appointment. Please review the questionnaire below and answer each question accurately. Once completed, please accept the terms and submit the form.
First Name *
Please provide your first name
Last Name *
Please provide your last name
Email Address *
Please provide your email address
Phone Number *
Please provide your phone number
Screening Questions
Have you had a fever greater than 37.5 C / 100 F in the past 14 days? *
You should take your temperature before coming to church. If you have a temperature above 37.5 C / 100 F, you should stay home.
In the last 14 days, did you have close contact with someone with symptoms of COVID-19, tested for COVID-19, or diagnosed with COVID-19? *
Close contact is when you are within 6 feet of an infected person for at least 15 minutes.
In the last 30 days, have you been outside of Canada? *
In the last two weeks, have you experienced any of the following symptoms? Cough, sore throat, feeling feverish (such as chills, sweating), loss of taste or smell, pink eye or runny nose. *
Confidentiality Agreement
Personal information on this form is collected under the authority of section 28 of Health Protection and Promotion Act, R.S.O. 1990, c. H.7, and Personal Health Information Protection Act, 2004, S.O. 2004, c. 3, Sched. A, and will be used by The Ossington Pentecostal Church (“OPC”) to take health, safety and operational measures against the coronavirus (referred to as COVID-19).

This information is retained in accordance with the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. M. 56 and will only be disclosed to authorized OPC staff and local public health unit(s), if required, in order to administer the above purpose.
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