COVID-19 Prescreening

The following form must be completely filled out before accessing our facilities. After you submit the form, a QR code will be emailed to you, as proof that you have filled out the form. Upon entry to our facilities, the QR code will be scanned at the door and the staff member will be shown your name, when you filled out the form and an informational alert letting them know if you may access the facility or not. Your personal answers will NOT be shared with our staff.

Your email address may also be used to contact you in the future for contact tracing in case of an outbreak. However, it will not be used for any other purpose.

Your name

Your email

1) Symptomatic or sick individuals will not be permitted at Town of Fairview facilities. Do you have any cold or flu-like symptoms not related to a pre-existing condition?
Yes
No

3) Do you have a fever?
Yes
No

4) Do you have a cough or sore throat?
Yes
No

5) Do you have shortness of breath or difficulty breathing?
Yes
No

6) Do you have a runny nose or nasal congestion?
Yes
No

7) Are you feeling unwell or fatigued?
Yes
No

8) Are you experiencing any nausea, vomiting or diarrhea?
Yes
No

9) Are you experiencing unusual muscle aches?
Yes
No

10) Are you experiencing unusual headaches?
Yes
No

11) Do you have conjunctivitis (pink eye)?
Yes
No

12) Have you or anyone in your household travelled outside of Canada in the last 14 days?
Yes
No

13) Have you had close contact with anyone who has a cough or fever (close contact is defined as face to face contact within 2 meters for a total of 15 minutes in any 24 hour period or physical contact, without wearing appropriate PPE)?
Yes
No

14) In the last 14 days, have you or anyone in your household been in close contact with someone that is suspected or confirmed to be infected with COVID-19 (close contact is defined as face to face contact within 2 meters for a total of 15 minutes in any 24 hour period or physical contact, without wearing appropriate PPE)?
Yes
No

15) I agree that while in Town of Fairview facilities I will remain 2 meters away from anyone not in my cohort group and will practice good hygiene by washing my hands often, cover coughs and sneezes and avoid touching my face.


16) By submitting this document I attest that the information contained on this form is correct to the best of my knowledge and that I have been adhering to the guidelines contained in Public Health Orders and as recommended by the Chief Medical Officer of Alberta.