Daily Health Self-Assessment Form



The safety of everyone is our top priority.In order to prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce, we are asking everyone to complete and submit this questionnaire prior to entering the Segal Centre.
Please respond to each of the following questions truthfully and to the best of your ability with your own writing instrument. Your participation is important to help us take precautionary measures to protect you and everyone who may come through our doors.

Name
(Last name, first name)
Email
Please select one of the following:
Phone number

Do you have one or more of the following symptoms:

Fever (above 38 degrees Celsius)?

Lethargy, fatigue, body aches?

Difficulty breathing or new/worsening cough?

Sudden loss of smell or taste?

Runny nose (not caused by allergies)?

Have you been in close contact with a person with COVID-19 or are you awaiting COVID-19 test results? Close contact is defined as:
Living with the person or having close and prolonged contact (without mask or facial protection within 2 metres for more that 15 minutes) with a confirmed COVID-19 infected person while the person was contagious, or
Having direct contact with contagious bodily fluids of the confirmed COVID 19 infected person (e.g. sneezed or coughed on the person without wearing the recommended personal protective equipment)


If you answered YES to any of the above questions, you may not enter the Segal Centre today to avoid infecting others. Contact the coronavirus info line 1 877 644-4545 and follow the instructions.

I commit to respecting the hygiene and preventive measures put in place to avoid the spread of the virus and thus protect my health and ensure my safety and that of others. This document will be treated in accordance with all laws and rules applicable to the processing, storage and protection of personal information.  I agree to inform a staff member of the Segal should I or any member of my onsite party receive a positive COVID-19 diagnosis within 14 days of my residence/presence at the Centre and provide the Centre with the date or date range of infection and date of testing.


* The information provided is confidential. The Segal Centre takes the necessary measures to ensure its protection.