Town of Huntsville COVID-19 Self-Assessment Form

The Town of Huntsville is committed to creating and maintaining municipal facilities that protects the health and safety of everyone wishing to visit or use them. To comply with the with the recommendations from the Simcoe Muskoka District Health Unit, the Town of Huntsville is requiring all individuals to complete an electronic COVID-19 Self-Assessment to determine if they are permitted to attend a Town of Huntsville facility.

Contact Details For The Individual Attending The Town Facility 

Mandatory Questions

Please review the following screening questions and provide an answer to determine your status:

1. In the last 10 days have you experienced any of the symptoms below that are not chronic or related to other known causes/conditions:
• Fever/chills
• Cough/barking cough
• Shortness of breath
• Decrease/loss of smell or taste
• Fatigue
• Muscle aches/joint pain
• Nausea/vomiting, and/or diarrhea
• Sore throat
• Runny or stuffy/congested nose
• Headache
  
  

  If you are fully vaccinated or under 12 years of age and not immune compromised and experienced the symptom(s) over 5 days ago and the symptom(s) have been improving for over 24 hours (48 hours for gastrointestinal symptoms) and you do not have a fever, answer “No”.
  
  If you are unvaccinated or immune compromised and experienced the start of symptom(s) over 10 days ago and the symptom(s) have been improving for over 24 hours (48 hours for gastrointestinal symptoms) and you do not have a fever, answer “No”.
  
  If you are symptomatic and tested negative for COVID-19 on a single PCR test or two rapid antigen tests (RAT) taken 24-48 hours apart and symptoms have been improving for over 24 hours (48 hours for gastrointestinal symptoms) and you do not have a fever, answer “No”.

2. In the last 14 days, have you 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)?
   

   Staying at home/self-isolation can be because of an outbreak or contact tracing

4. In the last 10 days, have you tested positive for COVID-19?
   If you are fully vaccinated or under 12 years of age and not immune compromised and the test was more than 5 days ago, answer “No”.
   
   This includes a positive COVID-19 test result on a lab-based PCR test, rapid antigen test or a home-based self-testing kit.
   
   
5. In the last 10 days (5 days for under 12 years of age), have you been identified as a “close contact” of someone who currently has COVID-19 and doesn’t live with you?
   If you are fully vaccinated and not immune compromised, answer “No”.
   
   
6. Do any of the following apply?
   
   • You live with someone who is currently isolating because of a positive COVID-19 test
   • You live with someone who is currently isolating because of COVID-19 symptoms
   • You live with someone who is waiting for COVID-19 test results
     
     

NOTE: Fully vaccinated is defined as an individual ≥14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series.

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Questions

If you have any questions about how to fill out this form, please direct them to Canada Summit Centre Customer Service: summitcentre@huntsville.ca 

Collection of Information 

This personal information is collected under the authority of the Health Protection and Promotion Act, 1990 s.5. Documents are maintained pursuant to the Municipal Freedom of Information and Protection of Privacy Act, 1991 and the Personal Health Information Protection Act, 2004. Data will  be stored in a secure electronic drive with access limited as described above. 

Questions about this collection can be directed to the Deputy Clerk, Town Hall, 37 Main Street East, Huntsville, ON, P1H 1A1, 705-789-1751 extension 2258, crystal.paroschy@huntsville.ca