COVID-19 Screening Tool

Each visitor to Kawartha Nordic is required to complete the following COVID-19 Screening every day they intend to visit. Please review our complete COVID Safety plan before your visit.

This screening is being completed by

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While visiting Kawartha Nordic today, you will be (check all the apply)

Do you have ONE or more of the following symptoms?

Fever and/or chills
Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
Cough or barking cough (croup)
Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)
Shortness of breath
Out of breath, unable to breath deeply (not related to asthma or other known causes or conditions you already have)
Decrease or loss of taste or smell
Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

Do you have TWO or more of the following symptoms?

Runny or stuffy/congested nose
Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have
Headache
New, unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, tension-type headaches, chronic migraines, or other known causes or conditions you already have)
Extreme tiredness
Unusual, fatigue, lack of energy (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)
Sore throat
Painful or difficulty swallowing (not related to post-nasal drip, acid reflux, or other known causes or conditions you already have)
Muscle aches/joint pain
Unusual, long-lasting (not related to a COVID-19 vaccine and/or flu shot in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)
Nausea, Vomiting, and/or Diarrhea
Not related to irritable bowel syndrome, anxiety, menstrual cramps, medication side effects, or other known causes or conditions you already have

In the last 10 days, has someone you live with been sick with symptoms associated with COVID-19 and/or tested positive for COVID-19 (on a rapid antigen test or PCR test)?

In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit?

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

In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19 (confirmed by PCR or rapid antigen test)?

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

Contact information is required for all visitors that join KN groups or use KN services.

This phone number or email address may be used by Kawartha Nordic and/or Peterborough Public Health for contact tracing, if a positive case is linked to Kawartha Nordic.

Personal information collected by this COVID-19 Screening Tool will be used only in relation to COVID-19 measures, and will only be shared as required by law.

By submitting this form, I declare that the information given here is true, correct, and complete. I am aware that I may be held liable for knowingly providing incorrect information.

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