COVID-19 Visitor Screening

Upon entering a Township of Puslinch facility all visitors and employees are required to fill out the COVID-19 Visitor Screening form. This form is retained in accordance with our record retention policy.

Name *

First

Last

Body Temperature? 37.8 C and over is considered a fever. *

Are you currently experiencing any of these symptoms that are new, worsening, and not related to a medical condition you already have: fever (temperature of 37.8 degrees and over), chills, cough or barking cough (croup) shortness of breath, sore throat, difficulty swallowing, runny or stuff/congested nose, decrease or loss of taste and smell, pink eye, headache that’s unusual or long lasting, digestive issues like nausea/vomiting, diarrhea and stomach pain, muscle aches that are unusual or long lasting, extreme tiredness that is unusual, or falling down often? *

In the last 14 days have you travelled outside of Canada? *

In the last 14 days, have you been in “close contact” of someone who currently has COVID-19? This includes getting a COVID Alert exposure notification. *

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *

Freedom of Information Disclaimer

Personal information on this form is collected under the authority of the Municipal Freedom of Information and Protection of Privacy Act and is maintained in accordance with the Municipal Freedom of Information and Protection of Privacy Act. Questions regarding the collection of this information may be directed to the Township Clerk’s office.