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COVID-19 Pre-Screening Questionnaire For NFFRC Entrants

All entrants of the Nature Fresh Farms Recreation Centre are required to pre-screen themselves prior to each entry to our facility. If you feel ill, do not enter the facility. Upon completion of the questionnaire, please be prepared to show entry confirmation to our staff at the entrance door.


1. Do you or anyone else indicated on this form have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.

Fever or chills (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher)

Cough or barking cough (croup)

Shortness of breath

Decrease or loss of smell or taste

Fatigue, lethargy, malaise and/or myalgias

Nausea, vomiting, and/or diarrhea

2. In the last 14 days, have you or someone in your household travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?

3. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing.

4. In the last 10 days, have you or someone in your household been identified as a “close contact” of someone who currently has COVID-19?  If public health has advised that you do not need to self-isolate select "No."

5. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? If you are fully immunized and/or have already gone for a test and got a negative result, select “No”.

6. In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? If you have since tested negative on a lab-based PCR test, select “No”.

7. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? If vaccinated in the last 48 hours & are experiencing mild symptoms that began after vaccination, select "No"


© 2020 The Municipality of Leamington 111 Erie Street North, Leamington, Ontario N8H 2Z9

Phone: 519-326-5761
Fax: 519-326-2481
Email: General Information

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