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Screening Questionnaire

St. Hilda’s Anglican Church (Fairbank)

COVID-19 Mandatory Screening Questionnaire


  1. Do you have any of the following symptoms?

    1. No

    2. Yes

      1. Fever greater than 38 degrees Celsius or 100.6 degrees Fahrenheit

      2. NEW or worsening cough or difficulty breathing/shortness of breath

      3. NEW general flu-like symptoms

      4. NEW chills or shakes

      5. NEW/unexplained feeling of malaise, confusion, or loss of consciousness

      6. NEW loss or change in ability to taste or smell

      7. Chest pain

      8. Nausea, vomiting, and/or diarrhea

  2. Have you travelled outside of Canada within the last 14 days?

    1. No

    2. Yes

  3. Have you had close UNPROTECTED contact with a probable or confirmed COVID-19 case?

    1. No

    2. Yes

  4. Have you had close UNPROTECTED contact with a person with acute respiratory illness who has been outside of Canada in the last 14 days?

    1. No

    2. Yes

If you answered “Yes” to any of the above questions, you are NOT permitted to attend the service at or enter St. Hilda’s Anglican Church (Fairbank). You should stay home and also seek medical attention if required.


*Close contact is defined as less than 2 meters for a prolonged period of time (i.e. Living with, caring for, in a relationship with).


**Unprotected is defined as not wearing the recommended Personal Protective Equipment (PPE) such as gloves, surgical mask.

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