Required fields are marked with asterisks (*)

Jasper Place Indoor Visitor Screening Tool

NOTE: This tool is for visiting Jasper Place Tenants INDOORS. If you have scheduled an OUTDOOR visit, please use the Outdoor Visitor Screening tool.

IMPORTANT: General Visitors are restricted at this time. Please call 684-2928 to schedule your window or virtual visit. The screening must be completed the day of the visit and no earlier.

Please complete all questions and submit your results. Thank you for your co-operation.


Do you have any of the following symptoms:

  • Fever (feeling hot to the touch, a temperature of 37.8 degrees Celsius or higher)
  • New or worsening cough
  • Shortness of breath
  • Sore throat
  • Runny nose or sneezing
  • Nasal congestion
  • Hoarse voice
  • Difficulty swallowing
  • New smell or taste disorder(s)
  • Nausea/vomiting, diarrhea, abdominal pain
  • Unexplained fatigue/malaise
  • Chills
  • Headache


1. Attestion of Compliance to Requirements during visit:

I have been informed of the visitor requirements and have reviewed the "INDOOR Family Visit Reminders":

  • You are to provide your own mask; material or procedure mask acceptable
  • Please wear a mask at all times. Wash/Sanitize your hands before and after visit
  • 2 visitors per visit, 1 visit per week
  • Maintain physical distancing as much as possible
  • No use of public washrooms or common areas. Visit only in the tenant's apartment/private patio
  • Please report at the main screening desk any deliveries you will be bringing to the tenant's apartment during your visit

I understand:

  • I must proceed directly to and from the tenant's room
  • There is no access to any common areas of Jasper Place
  • Infection, prevention and control (IPAC) protocols must be followed at all times, including wearing a procedure mask and sanitizing my hands before and after entering the building and the tenant room
  • Non-compliance of these requirements will results in the discontinuation of visits

2. Attestion of negative COVID-19 test:

I attest to Jasper Place screening staff that I have tested negative for COVID-19 within the last 2 weeks of today's date and subsequently not tested positive.

Any collection of personal information is made under the authority of the Ministry of Health Guidance Document: Section 77.7 of the Health Protection and Promotion Act (HPPA), R.S.O. 1990, c. H.7. Personal information is collected in compliance with the Municipal Freedom of Information and Protection of Privacy Act.

Personal information is collected for the purpose of complying with provincial orders related to the COVID-19 pandemic.  None of your personal information will be shared, rented, sold or otherwise released to any third party without your consent. 

Any questions about this collection should be directed to: Heather Mihichuk.

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