COVID-19 Visitor Self-Assessment to be completed by all Visitors entering a DSBN facility

The Public Health Agency of Canada (PHAC) is continually monitoring the COVID-19 pandemic in Canada. To support the process, the DSBN is mandating preventative screening measures to ensure the health and safety of all employees, contractors, subcontractors and visitors.

All visitors entering any DSBN facility must complete this form. The purpose of the questionnaire is to create a database of individuals connected to each facility for future communication but more importantly to serve as a pre-screening of all who wish to work at the worksite.

Personal Information

Name: Location:
Person Visiting: Time of Arrival:
  1. In the past 14 days, have you returned from travel to any other locations outside of Canada?
    If yes, date of return?
    (must be > 14+ days)
  2. Do you have any of the following unexplained minor symptoms: runny nose, sore throat, headache, muscle ache, nausea, anosmia (loss of smell), diarrhea or difficulty breathing?
  3. Has someone in your household, whom you have had close contact with and not worn PPE, tested positive for COVID-19?

If you have answered Yes to any of the above questions, please contact the DSBN representative you are scheduled to meet with prior to proceeding.

High Risk Factors:

The following groups are considered at high risk: over the age of 70, getting treatment that compromises (weakens) your immune system, having a condition that compromise (weakens) your immune system, having a chronic (long-lasting) health condition, regularly going to a hospital or health care setting for a treatment.

If you choose not to attend a DSBN facility as a result of a high risk factor, please contact the person you are scheduled to meet with.


Personal information and personal health information on this form is collected, used and disclosed in accordance with the Education Act, R.S.O. 1990, c.E.2, as amended, the Municipal Freedom of Information and Protection of Privacy Act. R.S.O 1990, c.M. 56, as amended and the Personal Health Information Protection Act , 2004, S.). 2004 c.3 Sched. A. and will be used for the purpose of preventative screening related to assessing entry into the DSBN buildings as a workplace and contract tracing requirements of Public Health and any similar or related purpose(s). Questions about this collection, use and disclosure should be directed to the Freedom of Information Coordinator, District School of Niagara, 191 Carleton Street, St. Catharines, ON L2R 7P4 905-641-1550.