Cornerstone Retirement Living

Ontario Senior Living

COVID-19 Screening

COVID-19 ACTIVE SCREENING TOOL FOR ALL RESIDENTS, STAFF, AND VISITORS

(Updated: February 28, 2023)

"*" indicates required fields



♢

1. In the last 10 days, have you experiences any of these symptoms?

Choose any/all that are new, worsening, and not related to other known causes or conditions that you already have.
 Select “No” if all of these apply:
• Since your symptoms began, you tested negative for COVID-19 on 1 PCR test or rapid molecular test, or 2 rapid antigen tests taken 24 to 48 hours apart and
• You do not have a fever and
• Your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea)
Q1*
Fever and/or chills
Temperature of 38 Degrees Celsius/100 Degrees Fahrenheit or higher

Cough
or barking cough (croup) Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have

Shortness of breath
Not related to asthma or other known causes or conditions you already have

Decrease or loss of smell or taste
Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

Muscle aches/joint pain
Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have)
If you received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing mild muscle aches/joint pain that only began after vaccination, select “No”

Fatigue
Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)
If you received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select “No”

Sore throat
Painful or difficulty swallowing (not related to post-nasal drip, acid reflux, or other known causes or conditions you already have)

Runny or stuffy/congested nose
Not related to seasonal allergies, being outside in the cold weather, or other known causes or conditions you already have

Headache
New, unusual, long lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)
If you received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing a headache that only began after vaccination, select “No”

Nausea, vomiting and/or diarrhea
Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have

♢

2. Have you been told that you should be currently quarantining, isolating, staying at home, or not attending a highest risk setting (e.g., a long-term care or retirement home)

This can include being told by a doctor, health care provider, public health unit, federal border agent, or other government authority.
Q2*

♢

3. In the last 10 days (regardless of whether you are currently self-isolating or not), have you tested positive for COVID-19, including on a rapid antigen test or a home-based self-testing kit?

If you have since tested negative on a lab-based PCR test, select “No”
Q3*

♢

4. In the last 10 days (regardless of whether you are currently self-isolating or not), have you been identified as a “close contact” of someone (regardless of whether you live with them or not) who has tested positive for COVID-19 or have symptoms consistent with COVID-19?

Q4*

♢

5. Do you agree to abide by the home’s health and safety practices, including those contained in Ministry for Seniors and Accessibility COVID-19 Guidance Documents for Retirement Homes in Ontario (June 24, 2022)

Q5*

♢

6. FOR STAFF ONLY: Have you demonstrated a negative rapid antigen result, as per company policy?

Q6*

♢♢♢

COVID-19 Safety Review (for Essential Visitors/Support Workers, General Visitors and Personal Care Service Providers)

Prior to visiting any resident, the Essential Visitor/Support Worker/General Visitor/Personal Care Service Provider verbally attests that they have:

1. Read/re-read the home’s visitor policy and Public Health Ontario’s document entitled Recommended Steps: Putting on Personal Protective Equipment (PPE)*
2. Watched/re-watched the following Public Health Ontario videos: Putting on Full Personal Protective Equipment, Taking off Full Personal Protective Equipment, and How to Hand Wash*
3. If the home is declared in outbreak, the Essential Visitor/Support Worker verbally attests that they have received training* on proper use of PPE (i.e., how to safely provide direct care, including putting on (donning) and taking off (doffing) required PPE, and hand hygiene)*
*Training provided by residence, or individual directed to Public Health Ontario resources.