COVID-19

COVID-19 Screening Form

The safety of our employees, partners, families and clients remain Capital Assist’s priority over everything else. As the COVID-19 outbreak continues to evolve, Capital Assist is monitoring the situation and closely following the recommendations of the local health unit and our government. We will periodically update guidance based on these recommendations.

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in the facility. Thank you.

Visitor's Name*
First Last
Personal Phone #*
Email Address*
Reason for Visit:*
Self-Declaration by Visitor
Have you returned from any country outside of Canada in the last 14 days?*
- Yes
- No
Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?*
- Yes
- No
Have you been in close contact with anyone who has traveled outside of Canada within the last 14 days?*
- Yes
- No
Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)?*
- Yes
- No
If the answer is ‘yes’ to any of the questions above, access to the facility will be denied and you will not be able to submit this form.
Visitor Signature*
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

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COVID-19

COVID-19 Screening Form

Self-Declaration by Visitor

If the answer is ‘yes’ to any of the questions above, access to the facility will be denied and you will not be able to submit this form.

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