A.A.S. COVID Screening Form

Ancaster Agricultural Society COVID Screening Form

* required field

First Name:*

Last Name: *

Email:*

Event you are attending:*

Date of event:*

Do you have any of the following new or worsening symptions or signs? Symptions should not be chronic or related to other known causes or conditions.* You must select one.

	Fever or chills
	Difficulty breathing or shortness of breath
	Cough
	Sore throat, trouble swallowing
	Runny nose/stuffy nose or nasal congestion
	Decrease or loss of smell or taste
	Nausea, vomiting, diarrhea, abdominal pain
	Not feeling well, extreme tiredness, sore muscles
	None of the above

Have you travelled outside of Canada in the past 14 days?*
Yes No *

Have you had close contact with a confirmed or probable case of COVID-19?*
Yes No *

If you have any of the symptoms or answered YES to any of the above questions, you have not passed. Do not attend the Ancaster Fairgrounds. You should go home to self-isolate immediately and contact your health care provider or Telehealth Ontario (1 866-797-0000) to find out if you need a COVID-19 test.