Pre-Visit Questionnaire

To prevent the spread of COVID-19 and reduce the potential risk of exposure, we are conducting a simple screening questionnaire prior to your visit. Your participation is important to help us take precautionary measures to protect you and everyone in the building. We thank you for taking the time to complete this questionnaire.

Visitor (Please type in the full name of the visitor)*

Phone Number*

Company (Please type in your company name if applicable)

Property Visited*

Reason for Visit*

1. Are you experiencing any of these new or worsening symptoms?*

Fever and/or Chills Cough or barking cough (croup) Shortness of breath Decrease or loss of taste or smell Muscle aches/joint pain Extreme tiredness

Yes

2. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?*

Yes

3. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?*

Yes

4. Have you been in close physical contact with someone who either:*

is sick with a new cough, fever, difficulty breathing, or other symptoms associated with COVID-19 in the last 10 days or returned from outside of Canada in the last 14 days? Close physical contact means any of the following while not wearing the appropriate personal protective equipment (PPE): • being less than 2 metres away in the same room, workspace, or area • living in the same home • being in the same classroom

Yes

5. Have you travelled internationally (outside of Canada) within the past 14 days?*

If exempt from federal quarantine requirements (for example, you are fully vaccinated and have met the specific conditions, or an essential worker who crosses the Canada-US border regularly for work), select “No.”

Yes

If the answer is “yes” to any of the questions or if you do not wish to complete this form you will not be able to visit the property. Please contact your employer to reschedule the work, inspection, or tour of the property.

Web Form Submitted By (Please type in your full name)*

I hereby state that the above questions have been answered to the best of my knowledge at the time of this form submission*

Confidentiality The contents of this Questionnaire are confidential between the parties and shall not be disclosed, except to meet any public health safety guidelines and/or regulations. Colonnade BridgePort will hold this questionnaire in its files for approximately 30 days from the date of the visit after which the questionnaire will be deleted/removed.

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