COVID-19 Access Screening Tool - Government

Name*
First Last
Phone*
Location*
Do any of the following apply to you or anyone in your household:
1. Experiencing any new or worsening COVID-19 symptoms including:
  - fever and/or chills
  - cough or barking cough (croup)
  - shortness of breath
  - decrease or loss of smell or taste
  - fatigue and/or malaise (for adults)
  - nausea/vomiting, and/or diarrhea (for <18 years of age)
2. Travelled outside of Canada in the last 14 days (and are not exempted from federal quarantine);
3. Told by any health care provider or health unit that you are a close contact OR should be isolating currently;
4. Received a COVID Alert exposure notification on your cell phone in the last 10 days (and have not been tested or waiting for your result);
5. Tested positive on a rapid antigen test, a home-based self-testing kit, or a PCR test for COVID-19, OR are awaiting results from a test.
One or more of these statements apply to me?*
- Yes
- No

Personal information on this form is collected under the authority of the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990 and will be used for contact tracing during the COVID‐19 pandemic. Questions about this collection should be directed to the Deputy Clerk/Manager of Legislative and Information Services, Norfolk County, 50 Colborne Street S, Simcoe, Ontario N3Y 4H3, Telephone: 519-426-5870 or 226-NORFOLK x 1261, email: [email protected].