The following COVID-19 self-assessment must be completed prior to entering the office or an off-site location for each individual office or off-site visit. Completing this self-assessment is mandatory, and self-assessments will be cross-referenced with those accessing the office to ensure compliance. The self-assessment process is in place to ensure the utmost safety of United Way staff, students, volunteers, and partners. Please contact the staff member facilitating your visit to our office if you have any questions or concerns.

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* 1. Please enter your first and last name.

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* 2. Please provide your phone number (we will only contact you in the event that you may have been exposed to COVID-19).

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* 4. Please indicate whether you will be accessing the office and/or an off-site location.

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* 5. Please select the date/time.

Date
Time

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* 6. Are you currently experiencing any of these symptoms?

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* 7. In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?

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* 8. In the last 14 days, have you been in close physical contact with someone who either is currently sick with new COVID-19 symptoms (like a cough, fever, or difficulty breathing) or returned from outside of Canada in the last 2 weeks with new COVID-19 symptoms (like a cough, fever, or difficulty breathing)?

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* 9. Have you traveled outside of Canada in the last 14 days?

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