Member/Patron Assessment Form

This document is to be completed if a member or patron with every contractor/vendor entering the facility. It will be completed by the staff member working with the contractor or the staff member with interacting with the vendor  

1. Are you experiencing any of the following Symptoms (new or worsening):


YesNo


YesNo


YesNo


YesNo


YesNo


YesNo


YesNo


YesNo


YesNo

2. Have you come in close contact with someone who is confirmed as having COVID-19 in the past 14 days?

YesNo

3. Have you been tested for COVID-19?

YesNo

4. Have you travelled outside of the province in the last 14 days?

YesNo

5. Have you been in close contact with anyone who has travelled outside the province in the last 14 days?

YesNo

Please note that as you enter the facility, you are still required to abide by physical distancing measures as set out by the government of newfoundland and labrador

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