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COVID-19 SCREENING QUESTIONNAIRE

In Support Of The Rock95 Toy Drive Dec.3/21 @ Ranch 2.0 Concert Hall

Are you currently experiencing any of the following symptoms; fever, chills, cough, shortness of breath, loss of smell or taste, fatigue, nausea or vomiting that are new or worsening?
In the last 14 days, have you travelled outside of Canada AND been advised to quarantine?
Has a doctor, health care provider, or public health unit told you that you should currently be isolating?
In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?
In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?
In the last 10 days, have you tested positive on a rapid antigen test or a homebased self-testing kit?
In the last 10 days, has someone in your household been identified as a “close contact” of someone who currently has COVID-19 and advised by a doctor, healthcare provider or public health unit to self-isolate in the last 10 days?
Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?
If you answered NO to all the above questions, please enter your Full Name, Phone Number and Email address below separated by commas:
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If you answered YES to any of the above questions, you will NOT be able to enter the venue due to health and safety concerns. Individuals with possible symptoms or exposure to COVID-19 should follow testing and self-isolation guidelines as per the SMDHU.

PRIVACY: The personal information on this form is collected under the authority of the Reopening Ontario (A Flexible Response to COVID-19) Act, 2020 and the Simcoe Muskoka District Health Unit.


The information will be used to screen you for heightened COVID-19 risk factors prior to your entering a Impact Live Event location. In the event of a confirmed COVID-19 diagnosis that coincides with your visit to an Impact Live event location, your information may be provided to public health authorities for purposes of contact tracing.


Please note that your information will be retained for 30 days. After which the information will be deleted from our system. By clicking "Submit" below you agree to the terms and conditions.