COVID-19 Public Self-Screening Tool

COVID-19 Self-Screening Tool

Welcome! Please help us continue to make Newmarket a safe place to work, live, and play by completing a self-assessment before entering. By answering these questions, you are helping protect yourself, Town of Newmarket staff, and your fellow residents


Notice of Collection of Personal Information

Personal information is collected under the authority of Municipal Act, 2001, S.O. 2001, c. 25. Your information will be used to screen for COVID-19 risk factors prior to entering a Town facility or participating in a Town program. In the event of a confirmed COVID-19 diagnosis that coincides with your visit, the Town will share your name and contact information to York Region Public Health for purposes of contact tracing.

Terms and Conditions

I acknowledge Covid-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious and that I have an elevated risk of contracting Covid-19 by being around other people in a public setting and I hereby assume the risks with respect to acquiring COVID-19 inherent in my entering a Town of Newmarket facility, including the associated risk of death, illness or severe bodily injury that may accompany Covid-19.

I hereby release and save harmless the Corporation of the Town of Newmarket and its employees and representatives from any and all claims and demands associated with my acquiring Covid-19, from my participation in Town of Newmarket programs or entering a Town of Newmarket facility, due to any cause whatsoever, including negligence, breach of contract, mistakes or errors in judgment. This Release of Liability shall be binding upon my heirs, next of kin, executors, administrators, assigns and representatives.


COVID-19 Self-Screening Tool


Facility Visiting

Please identify if you are:

Number of People You Are Screening

Full Name

Full Name #2

Phone Number #2

Full Name #3

Phone Number #3

Full Name #4

Phone Number #4

Full Name #5

Phone Number #5

Full Name #6

Phone Number #6

Full Name #7

Phone Number #7

Full Name #8

Phone Number #8

Full Name #9

Phone Number #9

Full Name #10

Phone Number #10

Phone Number

The following screening questions are for

COVID-19 Screening Form for

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 or chills
  • Difficulty breathing or shortness of breath
  • Cough
  • Sore throat, trouble swallowing
  • Runny nose/stuffy nose or nasal congestion
  • Decrease or loss of smell or taste
  • Nausea, vomiting, diarrhea, abdominal pain
  • Not feeling well, extreme tiredness, sore muscles

COVID-19 Screening Form for

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

COVID-19 Screening Form for

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

Not cleared to enter

As recommended by York Region Public Health, please go home to self-isolate immediately and contact your health care provider or York Region Public Health at 1-800-361-5653 to find out if you need a COVID-19 test.

Please contact your Supervisor to advise you are restricted from entering our facility. As recommended by York Region Public Health, please go home to self-isolate immediately and contact your health care provider or York Region Public Health at 1-800-361-5653 to find out if you need a COVID-19 test.

One or more individuals are not cleared to enter

Cleared to enter

Not cleared to enter

As recommended by York Region Public Health, please go home to self-isolate immediately and contact your health care provider or York Region Public Health at 1-800-361-5653 to find out if you need a COVID-19 test.

Please contact your Supervisor to advise you are restricted from entering our facility. As recommended by York Region Public Health, please go home to self-isolate immediately and contact your health care provider or York Region Public Health at 1-800-361-5653 to find out if you need a COVID-19 test.

cleared to enter

Please display to staff member before entering

Adhere to Public Health guidelines by properly wearing a face covering, washing/sanitizing your hands frequently, and maintaining a distance of at least 2 meters from others