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COVID-19 Contractor or Visitor Screening Questionnaire and Release of Liability Declaration V8 October 2021

Due to the recent outbreaks of COVID-19 across the globe and in our efforts to protect our employees and limit the spread of the virus, the Town of Gravenhurst requires you to complete this form prior to attending any of our facilities, even if you have been vaccinated. Preferred payment for services is by credit card or cheque.

What date do you plan to visit?

Who are you? Please choose the appropriate answer;

I am a visitor

I am a contractor

Have you been communicating or dealing with a certain staff member pertaining to this request? If yes, can you please provide their name.

Screening Questions to determine your status

Please answer the following questions.

Do any of the following apply to you? I am fully vaccinated against COVID-19 (it has been 14 days or more since a final dose of either a two-dose or a one-dose vaccine series). I tested positive for COVID-19 in the last 90 days (and now clear)

Yes

Are you currently experiencing any of the symptoms below? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Fever and or Chills (Temperature of 37.8 degrees Celcius or 100 degrees Fahrenheit or higher)

Cough or barking cough (croup) –Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)

Shortness of breath –Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)

Decrease or loss of taste or smell – Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

Muscle Aches and or joint pain - Unusual, long-lasting (not related to getting a COVID-19 vaccine in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)

Extreme tiredness - Unusual fatigue, lack of energy (not related to getting a COVID-19 vaccine in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

None of the above

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

Yes

In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?

Yes

In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?

Yes

Has anyone you live with travelled outside of Canada and been told to quarantine (per the federal quarantine requirements) in the last 14 days?

Yes

Has anyone you live with been identified as a “close contact” of someone who currently has COVID-19 and been told to self-isolate by a doctor, healthcare provider, or public health unit in the last 10 days?

Yes

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

Yes

In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit?

Yes

In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No."

Yes

First Name

Last Name

Primary Residence Civic Number

Primary Residence Street Name

Town or City Name

Province

Postal Code

Company Name (if applicable)

What is your email address?

Primary Phone Number

Secondary phone number

Completion of this declaration is mandatory. Failure to provide information will prevent you from entering or visiting the facility. Please complete your details to confirm you have read and understand this declaration.

If it is determined that you deliberately or negligently provided false answers to the above noted questions, you may be barred from entering any Town facility in the future.

Declaration

I acknowledge COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious and that I have an elevated risk of contracting COVID-19 by being around other people in a public setting, and I hereby assume the risks with respect to acquiring COVID-19 inherent in participating in work, or participating in activities and programs at a Town of Gravenhurst site(s), including the associated risk of death or severe bodily injury that may accompany COVID-19.
I hereby release and save harmless The Corporation of the Town of Gravenhurst and its employees and representatives from any and all claims and demands associated with my acquiring COVID-19, from working at or visiting a Town of Gravenhurst site, due to any cause whatsoever, including negligence, breach of contract, mistakes or errors in judgment. This Release of Liability shall be binding upon my heirs, next of kin, executors, administrators, assigns and representatives.

By checking this box I agree with the contents of this Declaration.

I have read this document in its entirety and fully acknowledge and understand its terms.

Please sign below using your mouse or finger if on a tablet or phone.

Clear

When you arrive at the facility:

You will be required to wear a face mask or face covering and sanitize your hands when you enter. Please note that public washrooms are currently closed at our facilities.

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COVID-19 Contractor or Visitor Screening Questionnaire and Release of Liability Declaration V8 October 2021

Screening Questions to determine your status

Declaration

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