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


  1. The Alberta Health Services COVID-19 SELF-ASSESSMENT (https://myhealth.alberta.ca/Journey/COVID-19/Pages/Assessment.aspx) has been truthfully completed today () for and the Alberta Health Services COVID-19 SELF-ASSESSMENT did not recommend self-quarantine nor COVID-19 testing.
  2. I understand and acknowledge that LPC Staff may not carpool with any staff members outside their cohort group unless they live in the same household. This is required to maintain the integrity of LPC's cohort groups and is inline with the Alberta government's carpooling recommendations.
  3. 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.
  4. 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.
  5. 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.
  6. The Staff Member indicated above will endeavour to maintain a healthy lifestyle including (but not limited to) healthy eating & sleep habits.

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: 092de5a5c88250fe93d9054cf12fe5c9089e0e1e
Timestamp Audit
May 22, 2020 10:26 pm MDTStaff COVID-19 Prescreening Questionnaire ({{gravity-field-id-3}}) Uploaded by LPC Registrar - registrar@loneprairiecamp.com IP 209.222.162.205
May 22, 2020 10:41 pm MDT Document owner info@loneprairiecamp.com has handed over this document to registrar@loneprairiecamp.com 2020-05-22 22:41:13 - 68.149.157.40