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COVID-19 screening form

Thank you for reserving our Mobile Multi-sensory Room. We look forward to working with you.

All users must complete our mandatory COVID-19 screening 48 hours prior to your reservation. Please note that if you do not complete the screening, we will not be able to open the Mobile Multi-sensory Room to you.

Thank you. We’ll see you soon!

COVID-19 Screening
1. Do you currently have or have you recently had a fever?
2. Do you have any of the following signs or symptoms?
3. Have you had close contact with anyone with respiratory illness or a confirmed or probable/suspected case of COVID-19 in the past 21 days?
4. Have you travelled outside of the province of British Columbia in the last 14 days?
5. Did you wear the required and/or recommended PPE according to the type of duties you were performing (e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures) when you had close contact with a suspected or confirmed case of COVID-19?
If you have answered ‘yes’ to questions 1 or 3, or have indicated signs or symptoms, you may need to reschedule your appointment. We will be in touch if that is the case. If you have answered ‘yes’ to question 4 but ‘yes’ to question 5, you may proceed with your appointment.
By checking this box I acknowledge that while the NSDRC is following the health and safety guidelines outlined by Worksafe BC and the Provincial Health Officer and that they are taking all reasonable precautions to disinfect the multi-sensory room and surfaces within the multi-sensory room, there are no guarantees that I will not come into contact with the SARS-CoV2 Virus.

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North Shore Disability Resource Centre

3158 Mountain Highway

North Vancouver, BC

V7K 2H5

phone: 604-985-5371

fax: 604-985-7594

email: nsdrc@nsdrc.org

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United Way member agency

The NSDRC was started by a group of families in 1976. In the years since, we have worked for a "Community for All" by developing and providing residential services, infant development programs, youth groups, community based services, and information and advocacy.

We are grateful for the opportunity to work, live and play on the unceded territory of the Coast Salish Peoples, including the territories of Musqueam, Squamish, and Tsleil-Waututh Nations.