Hub / Location of Visit(Required)Daniels SpectrumArtscape Daniels LaunchpadArtscape YoungplaceArtscape Wychwood BarnsArtscape Weston CommonArtscape Gibraltar PointArtscape SandboxArtscape Distillery StudiosFirst and Last Name(Required) Date of VisitMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time of Visit Hours : Minutes AM PM AM/PM Do you or anyone in your household have 1 or more of these new or worsening symptoms today or in the last 5 or 10 days: Fever and or chills / Cough / Difficulty breathing / Decrease or loss of taste or smell(Required) Yes No Do you or anyone in your household have 2 or more of these new or worsening symptoms today or in the last 5 or 10 days: Sore Throat / Headache / Feeling Tired / Running nose or nasal congestion / Muscle aches or joint pain / Nausea, vomiting or diarrhea(Required) Yes No *If the symptom is from a known health condition that gives you/them the symptom, select “No”. If the symptom is new, different or getting worse, select “Yes”. *If there is mild tiredness, sore muscles or joints within 48 hours after a COVID-19 vaccine, select “No”. If longer than 48 hours, select “Yes”. *Anyone who is sick or has any symptoms of illness, should stay home and seek assessment from their health care provider if needed. Check any that apply I am entering with minors from a different household I am under 18 years of age Questionnaire template courtesy of Workplace Safety and Prevention Services and Toronto Public Health
