Form Builder

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Visitor / Contractor Screening Form (v2022)

Please complete this form in its entirety. Bring the email confirmation with you to present to staff.

Visitor / Contractor Screening Questions

1. Do you, or anyone in your household, have any of the following new or worsening signs or symptoms unrelated to other known conditions?

- Fever or chills
- Cough or barking cough (croup)
- Difficulty breathing or shortness of breath
- Decrease or loss of smell or taste
- Nausea, vomiting, diarrhea if less than 18 years old
- Extreme tiredness or muscle aches if more than 18 years old

2. Have you or anyone in your household had any of the following?
- In the last 14 days travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements
- had a doctor, health care provider, or public health unit tell you that you should currently be isolating (staying at home)
- In the last 10 days been identified as a "close contact" of someone who currently has COVID-19
- In the last 10 days received a COVID Alert exposure notification on your cell phone
- In the last 10 days tested positive on a rapid antigen test or home-based self-testing kit

Do any of the listed symptoms, or conditions apply to you or anyone in your household?
 
Acknowledgement
 
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.

Clear


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