COVID-19 Visitor Self Assessment

This self-assessment must be completed by all visitors prior to entering our facilities. If you answer YES to any of the questions below, please do not visit.

Please enter this on your mobile device, or print the results, to present at your destination.

1. In the past 24 hours, have you experienced any *symptoms, not due to previously known chronic conditions diagnosed by a health care professional?

Yes No

2. In the past 24 hours, has anyone in your household (other than yourself) experienced any *symptoms, not due to a previously known chronic condition diagnosed by a health care professional and has not received a negative COVID-19 test result with respect to those symptoms?

Yes No

3. In the past 14 days, have you been in close contact with someone who has *symptoms of COVID-19, and 1) has travelled to a more heavily affected area of Canada 14 days prior to symptoms appearing or 2) had close contact with a confirmed case of COVID -19 or 3) has lived in or worked in a place with a confirmed outbreak of COVID-19 or 4) has been tested and results are unknown, and has not been told they can come out of isolation?

Yes No

4. In the past 14 days, were you or someone you live with 1) advised to consult with a heath care professional about COVID 19, but chose not to do so, or 2) advised to get tested for COVID-19, but chose not to do so, or 3) tested for COVID-19 due to *symptoms, but have not yet received the result?

Yes No

5. Have you returned from travel outside Canada in the past 14 days? (This does not include essential service workers who cross the border regularly for the purpose of performing an essential job or function as per the Order issued under the Quarantine Act).

Yes No

I confirm that I have reviewed the questions above and the information being submitted is true and correct.

If you answered YES to any of these questions, do not visit our locations. Call your health care provider or the Niagara Region COVID-19 Info-Line at 905-688-8248. A public health professional will give you detailed instructions to follow to protect you, your family and other members of the public.