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.

First Name: *

Last Name: *

Phone: *

If you are completing this screening for any other individuals with you, please enter their first and last name(s) here, also update total number of people. Leave blank if you are screening only for yourself.
Additional Names:
Total Number in your party (Max 10 and subject to current public health rules):

What location are you visiting today? *

City Hall
Welland Community Wellness Complex
Youth Arena
Main Arena
Library - Civic Square
Library - Diamond Trail
Library - Seaway Mall

* required fields

1. Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.

Fever/chills

Yes No

Difficulty breathing or shortness of breath

Yes No

Cough

Yes No

Sore throat. Trouble swallowing

Yes No

Runny nose/Stuffy nose or nasal congestion

Yes No

Decrease or loss of smell or taste

Yes No

Nausea, vomiting, diarrhea, abdominal pain

Yes No

Not feeling well, extreme tiredness, sore muscles

Yes No

2. Have you travelled outside of Canada in the past 14 days?

Yes No

3. Have you had close contact with a confirmed or probable case of COVID-19?

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.