COVID-19 Screening (Ministry of Health Ontario)

This screening tool is based on the latest COVID-19 case definitions and situation reports published by the World Health Organization. This is used to screen people who are suspected or confirmed of having COVID-19 throughout the health and emergency response system. Ensuring all health and safety providers are following the same screening protocol will help ensure consistency when dealing with suspected or confirmed cases of COVID-19.

Last updated: June 11, 2020. Sourced from: link

Please Write Your Full Name (or Guardian's Name) as an Electronic Signature *
Phone Number (e.g. 4167223393) *
Email Address (e.g. *
1. Did you travel outside of Canada in the last 14 days? *

2. Have you tested positive for COVID-19, or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE (Personal Protective Equipment)? *
*Close contact: being less than 2 metres away in the same room, workspace, or area for over 15 minutes, and/or living in the same home

3. Do you have any of the following symptoms? (Check all that applies) *

4. If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

5. Date of Service Visit *

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