Required fields are marked with asterisks (*)

Older Adults COVID-19 Screening Tool

Note: This tool must be filled out no earlier than 2 hours prior to your visit.

Please complete all questions and submit your results. Once submitted, an email will be sent to the email address provided in the tool below. Proof of completing this tool must be shown prior to entering the facility. Thank you for your co-operation.

Where applicable, proof of vaccine identification and of being fully vaccinated against COVID-19 is also required for entry with your completed and approved screening tool. Please visit www.thunderbay.ca/recreation for information on proof of vaccination requirements.

Anyone who is sick or has any symptoms of illness, including those not listed in this screening tool, should stay home and seek assessment from their health care provider if needed.

** Fully vaccinated means - it has been 14 or more days since your final dose of either a two-dose or a one-dose vaccine series **

Are you currently experiencing any of these symptoms?
Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

The symptoms listed here are the most commonly associated with COVID-19.  Anyone who is sick or has any symptoms of illness, including those not listed below, should stay home and seek assessment from the health care provided if needed.

  • Fever and/or chills (temperature of 37.8 degrees Celsius/100 degress Fahrenheit or higher)
  • Cough or barking cough (continuous, more than usual, making a whistling noise when breathing. Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have.)
  • Shortness of breath (out of breath, unable to breathe deeply. Not related to asthma or other known causes or conditions you already have)
  • Decrease or loss of smell or taste (not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have)

Are you currently experiencing  2 or more of the following symptoms?
Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

The symptoms listed here are the most commonly associated with COVID-19.  Anyone who is sick or has any symptoms of illness, including those not listed below, should stay home and seek assessment from the health care provided if needed.

  • Muscle aches/joint pain (unusual, long-lasting.  Not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hrs, a sudden injury, fibromyalgia, or other known causes or conditions you already have)
  • Extreme tiredness (unusual, fatigue, lack of energy.  Not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hrs, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)
  • Sore throat (painful or difficult swallowing. Not related to post-nasal drip, acid reflux, or other known causes or conditions you already have)
  • Runny or stuffy/congested nose (not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have)
  • Headache (new, unusual, long-lasting.  Not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hrs, tension-type headaches, chronic migraines, or other known causes or conditions you already have)

In the last 10 days, has someone you live with:

  • Been sick with symptoms associated with COVID-19, And/or
  • Tested positive for COVID-19 (on a rapid antigen test or PCR test)?

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

In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?

In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19 (confirmed by a PCR or rapid antigen test)?

If public health has advised you that you do not need to self-isolate, select “No.”

Have you travelled outside of Canada in the last 14 days AND been advised to quarantine per the federal quarantine requirements?

Acknowledgements:

I understand that if I do not pass this screening tool I am not to enter the facility.

I understand that if I become ill or develop symptoms while in the facility, I should leave the facility immediately, self-isolate and contact Public Health for information regarding COVID-19 testing.

Any collection of personal information is made under the authority of the Ministry of Health COVID-19 Guidance for facilities for sports and recreational fitness activities during COVID-19. 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: 625-2351.



Contact Us