Covid-19 Visitor Self-Screening Questionnaire

Important: this questionnaire must be completed on the same day as the participation at a Town of Whitby facility.

The health and well-being of our staff and community is the Town of Whitby’s top priority. To help prevent the spread of COVID-19, you must complete this assessment prior to being granted access to any of the Town's facilities.
As per the direction of Durham Region’s Medical Officer of Health, a mask or face covering must also be worn at all times while accessing public areas of these facilities.

Today's Date

First Name:

Last Name:

Phone Number:

Additional people with you (you can fill out this survey for multiple people, like your partner or children). For more than one person, add a comma: John Doe, Jane Doe etc.

Email:

Confirm Email:

Facility You Are Visiting

Time of Booking/Program

Risk Assessment Screening Questions

Have you travelled outside of Canada in the last 14 days and been advised to quarantine per the federal quarantine requirements?

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

Please note: * Close Contact means:

being less than 2 metres away in the same room or area for over 15 minutes or;
living in the same home.

Form Builder

Covid-19 Visitor Self-Screening Questionnaire

Important: this questionnaire must be completed on the same day as the participation at a Town of Whitby facility.

Risk Assessment Screening Questions