Required fields are marked with asterisks (*)

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. Do you have any of the following new or worsening symptoms 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
    • Sore throat/trouble swallowing
    • Runny/stuffy nose or nasal congestion
    • Extreme fatigue/lethargy (for adults 18 years or older)
    • Unusual Muscle/joint aches or pain (for adults 18 years or older)
    • Nausea/vomiting/diarrhea/stomach pain (for children under 18 years of age)

  2. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine 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)?

  4. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19? (If public health has advised you that you do not need to self-isolate (e.g. you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared), answer “No.”)

  5. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? (If you have already gone for a test and got a negative result, answer "No." If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, answer “No.”)

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

  7. In the last 14 days, has someone in your household (someone you live with) travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements? (If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, answer “No.”)

  8. In the last 10 days, has someone in your household (someone you live with) 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? (If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, answer “No.”)

  9. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? (If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, answer “No.” If you are fully vaccinated or have tested positive for COVID-19 in the last 90 days and since been cleared, answer “No.”)

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.

Please scroll down to the end of the page to click on the submit button

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