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

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

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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)
Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have
Shortness of breath
Not related to asthma or other known causes or conditions you already have
Decrease or loss of smell or taste
Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have
Muscle aches/Joint Pain
Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have)
Extreme tiredness
Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)
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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)
Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have
Shortness of breath
Not related to asthma or other known causes or conditions you already have
Decrease or loss of smell or taste
Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have
Nausea, Vomiting, and/or Diarrhea
Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have
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Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

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In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?

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In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?

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In the last 14 days, have you or anyone you live with travelled outside of Canada?

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Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

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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 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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