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 above, please DO NOT enter the MAG Canada facility.

Please contact your manager or 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 below, 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
New or worsening cough
Shortness of breath
Sore throat
Runny nose, sneezing, or nasal congestion (not including seasonal allergies)
Hoarse voice
Difficulty swallowing
New smell or taste disorders
Nausea/vomiting, diarrhea, abdominal pain
Unexplained fatigue
Chills
Headache

In the last 14 days, has someone you live with or someone you’ve been in close physical contact with tested positive for COVID-19?

Have you travelled outside of Canada, or had close physical contact with anyone who has traveled outside of Canada in the past 14 days?

Have you or anyone in your household been diagnosed with COVID-19 for which you did not receive “clearance from isolation” by Public Health?

Have you travelled outside of your region to a higher COVID area within the past Seven days

Have you had close contact with a person outside of your region from a higher COVID area within the past 7 days?

Are you aware of any of your close contacts in the past 7 days who have now developed symptoms and have not yet received a negative COVID test result?

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