COVID-19 Screening Questionnaire - Emmanuel Bible College

Name
First Last
Phone
Email
Date
MM slash DD slash YYYY
Do you currently have one or more of the COVID-19 symptoms below that are new or worsening?*
Symptoms should not be chronic or related to other known causes or conditions. If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”
- fever and/or chills
- cough or barking cough (croup)
- shortness of breath
- sore throat
- difficulty swallowing
- decrease or loss of smell or taste
- runny or stuffy/congested nose
- headache
- nausea/vomiting or diarrhea
- muscle aches/joint pain
- fatigue
- pink eye
- stomach pain
- falling down often (for older adults)
- none of the above
Has a doctor, health care provider or public health unit told you that you should currently be isolating (staying at home)?*
This can be because of an outbreak or contact tracing.
- Yes
- No
Do you live with someone who has been told by a doctor, health care provider or public health unit that they should currently be isolating?*
If you are fully vaccinated, select "No." If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”
- Yes
- No
In the last 14 days, have you or anyone you live with travelled outside of Canada?*
- Yes
- No
If you answer YES to any one of the questions above, PLEASE DO NOT enter this location AND contact either your health care provider or Telehealth Ontario (1-866-797-0000) to get advice or an assessment, including if you need a COVID-19 test.
Attestation
- Yes
- No
I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and can still be contagious. It is possible to contract COVID-19 in any public space, including a classroom, library, dorm, or office setting. Be reassured that Emmanuel Bible College continues to follow the COVID-19 guidelines set in place by our governing bodies to ensure the health and safety of everyone. By completing this form, I acknowledge that upon entering the premises of Emmanuel Bible College I assume any risks associated with COVID-19.