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Visitor/Contractor COVID-19 Screening Tool
Complete this form and submit it prior to entering our greenhouse facility for your scheduled appointment . If you answer "Yes" to any of the questions below, DO NOT ENTER OUR FACILITY.
Name
*
First
Last
Date
Date Format: MM slash DD slash YYYY
Time
*
:
HH
MM
AM
PM
Who is your scheduled meeting with? (Please Select)
*
Albert Grimm
Barbara Jeffery-Gibson
Gina Marchionda
Ken Mahaffey
Ryan Gibson
Scott MacArthur
Rodd Gibson
Wayne Fast
Company Name
*
Phone Number
*
Enter your email address if you would like to receive a copy of this screening tool.
Do you have any of the following:
1. Fever / chills
*
Yes
No
2. New Cough or a cough that is getting worse
*
Yes
No
3. Difficulty breathing
*
Yes
No
4. Shortness of breath (even when sitting or walking regularlry)
*
Yes
No
5. Sore throat (not due to allergies)
*
Yes
No
6. A runny or congested nose (not due to allergies)
*
Yes
No
7. Unusual level of fatigue
*
Yes
No
9. Nausea / vomiting, diarrhea, or loss of appetite
*
Yes
No
10. Feeling unwell for an unknown reason
*
Yes
No
Have you been in close contact with someone who is either sick, sent for testing, or has confirmed COVID-19 in the past 14 days?
*
Yes
No
Have you returned from travel outside Canada in the past 14 days?
*
Yes
No