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: Phone: (for contact tracing purposes only)
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: Fever, chills, cough that is new or worsening, barking cough (making a whistling noise when breathing), shortness of breath, difficulty swallowing, stuffy or congested nose, pink eye, runny nose, sore throat, headache, muscle ache, digestive issues like nausea/vomiting/diarrhea or stomach pain, decrease or loss of taste or smell, extreme tiredness that is unusual, falling down often or difficulty breathing?
  3. In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?
  4. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? Note: If you already went for a test and got a negative result, select “No.”
  5. Has a doctor, health care provider or public health unit, told you that you should be currently isolating (staying at home?)
  6. Does anyone in your household have a new or worsening symptoms of COVID-19 and has been recommended for isolation and testing?

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 Board of Niagara, 191 Carleton Street, St. Catharines, ON L2R 7P4 905-641-1550.