Date * Town facility you are entering * Ballinafad Community Centre Erin Community Centre Hillsburgh Community Centre Station 10 Station 50 Town Hall Roads Shop Full Name * Please enter your first and last name Phone Number * Email * Please enter your email address to receive a confirmation of completion. Are any of the following symptoms new or getting worse? If YES, to two or more symptoms entrance is prohibited. If NO, proceed to the next question. * Fever Sore throat Cough New shortness of breath Muscle aches Fatigue Headache Loss of Smell Nausea Runny nose Loss of appetite None of the Above Have you traveled outside of Canada in the last 14 days? * Yes No If you travelled outside of Canada in the last 14 days, did you meet all of the re-entry requirements? Yes No Not Applicable Have you recently had a COVID-19 test and are currently awaiting results? If YES, entrance is prohibited. If NO, proceed. * Yes No Does someone you are in close contact with have COVID-19? * Yes No If you have answered yes to the above, then have you met the provincial requirement of self monitoring/isolation? If no then entrance is prohibited * Yes No Not applicable Consent for storing submitted data * Yes
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