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
  • Coughing
  • Sore Throat
  • Decrease or loss of taste or smell
  • Runny Nose / Congestion - in absence of underlying reason for these symptoms such as seasonal allergies, post nasal drip, etc
  • Difficulty Swallowing
  • Digestive issues like nausea/vomiting, diarrhea, stomach pain – not related to irritable bowel syndrome or menstrual cramps
  • Pink Eye

The following should not be related to receiving a COVID-19 vaccine in the last 48 hours

  • Muscle aches/joint pain – Unusual or long lasting (not related to a sudden injury or fibromyalgia)
  • Headache and not feeling well – Unusual or long lasting
  • Extreme tiredness – Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction)

COVID-19 Screening Form for

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

Notes

If you are fully vaccinated*, select "No"

If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select "No".

*Fully vaccinated is defined as an individual who has had at least 14 days pass after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series.

COVID-19 Screening Form for

In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?

Notes

If you are not fully vaccinated* AND live with an individual who has recently travelled outside of Canada, you are permitted to attend work but are required to stay home except for essential reasons for the duration of the individual’s isolation period.

Essential reasons include: attending school/child care/work and essential errands such as, obtaining groceries, attending medical appointments or picking up prescriptions.

*Fully vaccinated is defined as an individual who has had at least 14 days pass after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series.

COVID-19 Screening Form for

In the last 14 days, have you been identified as a close contact of someone who currently has COVID-19?

Note

If you are fully vaccinated* and have not been advised to self-isolate by public health, select "No".

*Fully vaccinated is defined as an individual who has had at least 14 days pass after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series.

COVID-19 Screening Form for

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

Note

This can be because of an outbreak or contact tracing.

COVID-19 Screening Form for

In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?

Note

If you are fully vaccinated* and/or have already gone for a test and got a negative result, select "No".

COVID-19 Screening Form for

In the last 10 days, have you tested positive on a rapid antigen test or a homebased self-testing kit?

Note

If you have since tested negative on a lab-based PCR test, select "No".

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