Covid-19 Screening Form

    Introduction:

    • Everyone planning to attend an in-person program at an Innisfil ideaLAB & Library location is required to complete the pre-screening for COVID-19
    • Screening must be completed daily, before attending a program or an ideaLAB & Library branch.
    • This screening tool is based on the Ministry of Health’s COVID-19 Patient Screening Guidance Document, V. 4.0 - June 11, 2020.
    • This information will be maintained in accordance with the Library’s Confidentiality and Protection of Privacy Policy, and will only be provided to the Simcoe Muskoka District Health Unit when necessary for contact tracing purposes related to the COVID-19 pandemic

    Your Information




    Screening Questions


    For individuals 18 years of age or older

    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.

    Choose any/all that are new, worsening, and not related to other known causes or medical conditions.

    Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or
    higher

    Continuous, more than usual, making a whistling noise when breathing, not related to other known causes or conditions (for example, asthma, post-infectious reactive airways, COPD)

    Out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma)

    Not related to other known causes or conditions (for example, allergies, neurological disorders)

    Not related to other known causes or conditions (for example, seasonal allergies, acid reflux)

    Painful swallowing, not related to other known causes or
    conditions

    Conjunctivitis, not related to other known causes or conditions
    (for example, reoccurring styes)

    Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather)

    Not related to other known causes or conditions (for example,
    tension-type headaches, chronic migraines)

    Not related to other known causes or conditions (for example, irritable bowel syndrome, menstrual cramps)

    Not related to other known causes or conditions (for example, a sudden injury, fibromyalgia)

    Fatigue, lack of energy, not related to other known causes or conditions (for example, depression, insomnia, thyroid dysfunction)

    For older people

    For individuals under the age of 18

    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.

    Choose any/all that are new, worsening, and not related to other known causes or medical conditions.

    Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or
    higher

    Continuous, more than usual, making a whistling noise when breathing, not related to other known causes or conditions (for example, asthma, post-infectious reactive airways, COPD)

    Out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma)

    Not related to other known causes or conditions (for example, allergies, neurological disorders)

    Painful swallowing, not related to other known causes or
    conditions (for example, seasonal allergies, acid reflux)

    Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather)

    Not related to other known causes or conditions (for example,
    tension-type headaches, chronic migraines)

    Not related to other known causes or conditions (for example, irritable bowel syndrome, menstrual cramps)

    Fatigue, lack of energy, poor feeding in infants, not related to other known causes or conditions (for example, depression, insomnia, thyroid dysfunction, sudden injury)

    If you are an essential worker who crosses the Canada-US border regularly for work,
    select “No”.