Form

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
cough
difficulty breathing
muscle aches
fatigue (feeling tired)
headache
sore throat
runny nose
hoarse voice
difficulty swallowing
loss of sense of smell or taste
diarrhea
nausea or vomiting

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)