Form

Required fields are marked with asterisks (*)

COVID-19 Screening Questionaire- Recreation

The purpose of this questionnaire is to take preventative measures to ensure the health and safety of all Municipality of Kincardine residents. Please fill out this form before entering the building.

Full Name:

Phone:

Date:

Time:

Company Name/Purpose of visit:

Which Municipal Facility are you entering?

Symptoms for COVID-19 range from mild to severe. Some symptoms are similar to the flu and other common respiratory infections:

Fever and/or chills

Shortness of breath

Cough or barking cough (croup)

Extreme iredness

Muscle aches/joint pain

Decrease or loss of taste or smell

Sore Throat

Runny or Congested Nose

Nausea, Vomiting and/ or diarrhea

Do you have any of the above symptoms that are unusual for you, not related to seasonal allergies or other known causes or conditions?

Yes

Personal information is collected under the authority of the Municipal Act, for the purpose of creating a record to be used for contact tracing for people who enter Municipal facilities. Questions about the collection of the personal information may be addressed to the Clerk of the Municipality of Kincardine, 1475 Concession 5, R.R. 5, Kincardine, Ontario N2Z 2X6. Phone: 519-396-3468

Contact(s)