McRae Imaging Visitor Screening

The McRae Visitor COVID-19 Screening Tool is focused on keeping our workers and workplace safe during the pandemic. Let’s work together to stop the spread.

First Name *

Last Name *

Email Address *

Phone Number *

Purpose of Visit

Required Screening Questions

Do you have any of the following new or worsening symptoms or signs? Symptoms cannot be chronic or related to other known causes or conditions.

Fever or chills? *YesNo

Difficulty breathing or shortness of breath? *YesNo

Cough? *YesNo

Sore throat, trouble swallowing? *YesNo

Runny nose / stuffy nose or nasal congestion? *YesNo

Decrease or Loss of smell or taste? *YesNo

Nausea, vomiting, diarrhea, abdominal pain? *YesNo

Not feeling well, extreme tiredness, sore muscles? *YesNo

Have you travelled outside of Canada in the past 14 days?

YesNo

Have you had close contact with a confirmed or probable case of COVID-19?

YesNo

* By submitting this form, I declare that the information I have given is true, correct, and complete. I am aware that I may be held liable for knowingly providing incorrect information. *I Agree

Results of Screening Questions:

YOU ARE NOT ALLOWED TO ENTER THE WORKPLACE

Please self-isolate immediately and contact your health care provider or TeleHealth Ontario (1866-797-0000) to find out if you need a COVID-19 test.

Results of Screening Questions:

Thank you, {name-1-first-name}. You are welcomed to enter the workplace.

Please do not fill in this field.

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