Form Builder

Required fields are marked with asterisks (*)

Jasper Place Outdoor Visitor Screening Tool

NOTE: This tool is for visiting Jasper Place Tenants OUTDOORS. If you have scheduled an INDOOR visit, please use the Indoor 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.

First Name

Last Name

Enter your email address

Enter your phone number

Extension

Relationship to Tenant

Tenant being visited (Name)

PART 1

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

Any of the above?

Yes

Have you travelled or had close contact with anyone that has travelled outside of Northern Ontario in the past 7 days? Northern Ontario stretches from Parry Sound to the Manitoba border.

Yes

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

Yes

PART II

Attestion of Compliance to Requirements during visit:

I have been informed of the visitor requirements and have reviewed the "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 gifts or pets or food at visit, provide to main screening desk
We continue to accept deliveries on your behalf daily (8am - 8pm)

I understand that non-compliance will result in discontinuation of visits and if physical distancing is not maintained the Resident will be isolated for 14 days and a COVID-19 test completed.

Do you agree or disagree with the above?

Disagree

Agree

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.