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Daily Screening Questionnaire

Please enter these questions before you enter any municipal facility.  

Based on your responses, please proceed with the recommendations identified by Public Health and show your supervisor or entrance screener for entry.

PLEASE MAKE SURE YOU READ THE QUESTIONS (THEY ARE UPDATED FREQUENTLY)

For Lakeshore Staff: If you are experiencing any COVID-19 Symptoms, do not come to work.  Please fill out this form, call your supervisor and stay home.

Type

Please read the following and answer below:

1. Are you currently experiencing any one of the symptoms below that are new or worsening?  Symptoms should not be chronic or related to other known causes or conditions.

  • Severe difficulty breathing -struggling for each breath, can only speak in single words
  • Severe chest pain - constant tightness or crushing sensation
  • Feeling confused or unsure of where you are
  • Losing consciousness
  • Fever and/or chills - temperature of 37.8 degree Celsius/100 degrees Fahrenheit or higher
  • Cough or barking cough (croup) - 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
  • Muscle aches/joint pain - unusual, long-lasting (not related to getting a COVID-19 vaccine in the last 48 hours), 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 hours), depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have
  • Sore throat - pain or difficulty 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 hours, tension-type headaches, chronic migraines, or other known causes or conditions you already have)
  • Nausea, vomiting and/or diarrhea - not related to irritable bowel syndrome, anxiety, menstrual cramps, medication side effects, or other known causes or conditions you already have.

2. In the last 10 days, has someone you lived with:

  • been sick with symptoms associated with COVID-19? and/or
  • tested positive for COVID-19 (on a rapid antigen test or PCR test)?

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

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

5. In the last 10 days, have you been identified as a "close contact" or someone who currently has COVID-19 (confirmed by a PCR or rapid antigen test) Note: if public health has advised you that you do not need to self-isolate, answer "No".

6. In the last 14 days, have you travelled outside of Canada? Note: if exempt from federal quarantine requirements as directed by the border agent at your point of entry (for example, you have two or more doses of a COVID-19 vaccine and have met the specific conditions, or an essential worker who crosses the Canada-US border regularly for work), answer "No".

Should you answer yes to any of the above questions, please proceed with completing the online COVID-19 self-assessment at https://covid-19.ontario.ca/self-assessment/

Please answer:

If you are not experiencing any of the symptoms listed above, and answered NO to all of the questions then you may enter the building and begin working.

Notice of Collection

This information will only be used by public health officials for contact tracing. All information will be deleted in 28 days.

The personal information collected on this form is collected pursuant to thethe Reopening Ontario (A Flexible Response to COVID-19) Act, 2020, the Occupational Health and Safety Act, R.S.O. 1990, c. O.1, and the Municipal Act, 2001, S.O. 2001, c. 25 and in accordance with the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. M.56.  Questions regarding the collection, use and disclosure of this personal information may be directed to the:

Manager of Legislative Services,
Municipality of Lakeshore, 419 Notre Dame, Belle River, ON N0R 1A0
Telephone:  519-728-2700, Ext. 235 clerk@lakeshore.ca

 

Agreement
  • I consent to the collection of my personal information by the Municipality of Lakeshore for the purpose described in the notice of collection (above);
  • That the information that I provided is accurate and truthful; and,
  • That this information may be disclosed to the Windsor-Essex County Health Unit in the event that the Health Unit requests the information from the Municipality.


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Municipal Services

Monday to Friday: 8:30 AM to 4:30 PM

419 Notre Dame St.

Belle River, ON N0R 1A0

Phone: 519-728-2700

Toll Free: 1-877-249-3367

Fax: 519-728-9530

info@lakeshore.ca

Atlas Tube Recreation Centre

Monday to Friday: 6:00 AM to 9:30 PM

Saturday and Sunday: 6:00 AM to 8:30 PM

447 Renaud Line

Lakeshore, ON N0R 1K0

Phone: 519-727-0470

recinfo@lakeshore.ca

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