This assessment tool must be completed before each visit to a Zorra recreation facility and by each visitor per Ontario Regulation 364/20. It is not to take the place of medical advice, diagnosis or treatment.

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1. Name of Visitors (Please include all participants and supervising adults from the same household)

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2. Contact Information

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4. Start time of rental?

Time

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5. Do you have any of the following symptoms?
Select symptoms if they are new or worsening and not related to chronic or known conditions

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6. Do you reside in a public health which is under Red or Grey COVID-19 measures or have you travelled outside of Canada in the past 14 days?

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7. Have you had close contact with a confirmed or probable case of COVID-19?

Results of Screening Questions:
• If you have no symptoms and answered NO to questions 6 or 7, you may enter the facility
• If you have symptoms or answered YES to questions from 6 or 7, you may not enter the facility today. Please contact you health care provider, your local health unit or telehealth.
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100% of survey complete.

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