Self-Screening Assessment Questionaire

Our Commitment

The Municipality of Middlesex Centre is committed to protecting the privacy and confidentially of the information provided through the submission of this form, which includes upholding our privacy obligations as set out in all applicable privacy legislation including, but not limited to, the Freedom of Information and Protection of Privacy Act.


Wed Oct 27 2021

Are you currently experiencing one or more of the following symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions.

1. Are you experiencing a fever or chills?

2. Are you suffering from shortness of breath?

3. Do you have a cough or barking cough (not related to asthama, post-infectious reactive airways, COPD, or other known causes.)?

4. Are you experiencing a decrease or loss of smell or taste?

5. Are you feeling unwell, fatigue or lethargic?

6. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?

7. In the last 10 days, have you tested positive 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".

8. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

9. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No". If you are fully immunized or have tested positive in the past 90 days and have since been cleared, select "No"

10. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? (If the individual experiencing symptoms received a covid-19 vaccination in the last 48 hours and is experiencing mild fatigue, muscle aches and/or joint pain that only began after vaccination, select "No")(If you are fully immunized or have tested positive for covid-19 in the last 90 days and since been cleared select "No").

11. In the last 10 days, have you been identified as a "close contact" of someone who has covid-19? if public health has advised you that you do not need to self-isolate (eg: you are fully immunized or have tested positive for covid-19 in the last 90 days and since been cleared, select "No").