MAG Canada Visitor COVID-19 Screening Questionnaire

Please use the form below to complete your Visitor COVID-19 Screening Questionnaire.

Todays Date:

Name:

Base Location

If you answer “Yes” to any of the below, please DO NOT enter the MAG Canada facility. Please contact your MAG point of contact or the Operations Manager. You are not permitted to return until clearance from COVID- 19 has been issued. Please contact your local Public Health office, health care provider or Telehealth for more guidance.

If you answer “NO” to all the above, you may enter the MAG Canada facility as long as you follow public health guidelines and the procedures listed in the MAG Canada COVID Plan.

Do you have any of the following new or worsening symptoms or signs?

Fever and/or chills
Cough or barking cough (croup)
Shortness of breath
Sore throat
Difficulty swallowing
Runny or stuffy/congested nose
Decrease or loss of taste or smell
Pink eye
Unusual or long-lasting headache
Digestive issues like nausea/vomiting, diarrhea, or stomach pain
Muscle aches
Extreme tiredness
Falling down often

In the last 14 days, have you traveled outside of Canada?

In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

In the last 14 days, have you received a COVID Alert exposure notification on your phone?

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

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