Staff COVID-19 Prescreening Questionnaire ({{gravity-field-id-3}})


  1. was tested for COVID-19 within the past 10 days and received a negative test result OR was tested for COVID-19 within the past 6 weeks, received a negative test result and has been offsite for less than 2 weeks.
  2. The Alberta Health Services COVID-19 SELF-ASSESSMENT (https://myhealth.alberta.ca/Journey/COVID-19/Pages/Assessment.aspx) has been completed today () for and the answer to all the Self-Assessment questions was a truthful "No". Furthermore, the Alberta Health Services COVID-19 SELF-ASSESSMENT did not recommend self-quarentine nor COVID-19 testing.
  3. I understand and acknowledge that LPC Staff may not carpool unless the driver and passengers are in the same cohort group. The only exception is if there is only 1 passenger, that passenger sits in the back seat on the passenger side and everyone adheres to the rest of the Alberta government's carpooling recommendations.
  4. The Staff Member indicated above has installed and activated the ABTraceTogether App on their cellphone (if compatible) and will continue running this app while serving at Lone Prairie Camp and for at least 2 weeks afterwards.
  5. The Staff Member indicated above has installed and activated the COVID Alert App on their cellphone (if compatible) and will continue running this app while serving at Lone Prairie Camp and for at least 2 weeks afterwards.
  6. The Staff Member indicated above will wear a mask whenever running errands offsite during work hours and whenever unable to maintain 2 meters of distance from other staff members. Lone Prairie Camp also echoes Alberta Health Service's recommendation to wear a mask in public when it's difficult to maintain physical distancing of 2 metres at all times.
  7. The Staff Member indicated above will consent to any COVID Testing recommended by Alberta Health Services while serving at Lone Prairie Camp and for at least 2 weeks afterwards.
  8. The Staff Member indicated above will endeavour to maintain a healthy lifestyle including (but not limited to) healthy eating & sleep habits.
Please list the full names of everyone in your cohort group. Don't forget to include everyone who lives in your house and anyone you haven't maintained social distance with during the past 2 weeks. Although it is not required, you may include LPC staff. However, it is important to remember that everyone within a cohort group can only be part of ONE cohort group:
It is important that this document is signed by the participant (or their parent/guardian if the participant is under 18 years old) on the day of arrival. Please complete the Alberta Health Services COVID-19 SELF-ASSESSMENT and digitally sign this document before arrival but not before the day of arrival.

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Signature Certificate
Document name: Staff COVID-19 Prescreening Questionnaire ({{gravity-field-id-3}})
lock iconUnique Document ID: b24321ddfd6087e1790bd25160a474e386e398f7
Timestamp Audit
May 22, 2020 10:26 pm MSTStaff COVID-19 Prescreening Questionnaire ({{gravity-field-id-3}}) Uploaded by LPC Registrar - registrar@loneprairiecamp.com IP 69.168.162.91
May 22, 2020 10:41 pm MST Document owner info@loneprairiecamp.com has handed over this document to registrar@loneprairiecamp.com 2020-05-22 22:41:13 - 68.149.157.40