Hospice Niagara · NH Staff Screening

Hospice Niagara Screening Form

Privacy Statement

To ensure the safety of all staff, volunteers, clients, families and visitors, an active screening is required for everyone wishing to enter our sites to screen for COVID-19. Your screening result, i.e. "Green" or "Red" will be emailed to you upon completing this IPAC Screening Tool. The "Green" or "Red" result, along with your email address will also be provided to Hospice Niagara and will be purged from Hospice Niagara systems within one week. Hospice Niagara respects your privacy and will protect your personal information and adhere to all legislative requirements with respect to protecting privacy.

First Name

Last Name

Email address

Please re-enter your email address

Please select the program/area that you are planning to attend today

Have you had a fever (37.8 degrees C or greater) in the last 48 hours?

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

Have you tested positive for COVID-19 and not been medically cleared?

Have you had close contact with anyone who has severe respiratory symptoms (without appropriate PPE) in the past 14 days?

Have you had contact with a confirmed case of COVID-19 without appropriate PPE?

Fever or chills

New onset of cough

Worsening chronic cough

Lost sense of taste or smell

Shortness of breath

Sore throat

Runny or congested nose (not allergies)

Unexplained fatigue

Unusual headache

Nausea, vomiting, diarrhea, loss of appetite

Feeling unwell for an unknown reason

Pink eye (conjunctivitis)

I acknowledge and confirm that the information provided above is truthful and accurate.

Generate a new image Play the audio code

Enter the code from the image