Daily Screening Form

As part of our commitment to providing a safe and healthy workplace and environment, participants/parents/guardians/visitors are required to complete this screening each time prior to entering Township of Uxbridge facilities or programs. Your answers will only be used to generate a pass / fail response. By answering these questions honestly, you are helping to ensure a safe environment and to minimize the spread of COVID-19

The information recorded in the screening is confidential. I, understand and agree that this form is being retained by the Township of Uxbridge and/or designate for a period of 30 days and shall only be disclosed to third parties in order to respond to a health and safety concern and/or as required by law. If you are concerned that you may have COVID-19 or been exposed to it, call the Durham Health Connection Line (1-800-841-2729) or Telehealth (1-866-797-0000) to confirm next steps.

Please review the following screening questions:

  1. Are you currently experiencing one or more of the following symptoms, any/all that are new or worsening, and not related to other known causes or conditions you already have?

    • Fever and/or chills (temperature of 37.8 C/100.04 F or greater)
    • Cough or barking cough
    • Shortness of breath
    • Loss of sense of smell or taste
    • Sore throat
    • Runny/stuffy nose
    • Headache, fatigue, aches or pain
    • Nausea, vomiting, or diarrhea


      Note: If you are fully vaccinated and not immune compromised, you can answer NO to the above question if you experienced the symptoms more than 5 days ago AND symptoms have been improving for 24 hours.

  2. Has a doctor, health care provider, or public health unit told you that you should currently be isolating?

  3. Have you been tested for COVID-19 and are waiting for laboratory results?

  4. Do you live with someone who is either experiencing COVID-19 symptoms, waiting for COVID-19 test results, or isolating because of a positive COVID-19 test?

  5. In the last 10 days, have you been identified as a “close contact” and you are not fully vaccinated or you are immune compromised?

  6. Have you travelled outside of Canada within the past 14 days and been told to quarantine?