COVID-19 Pre-screening Questionnaire

Water Service Agreement

This form is for resident use only.

Please note: For Emergency Water Shut Off requests during regular business hours, please contact Access Richmond Hill by telephone 905-771-8800, between 8:30 a.m. to 4:30 p.m., Monday to Friday.

Due to COVID-19, residents must submit a screening questionnaire for in-person service. This information will be used for contract tracing purposes.

COVID Symptoms or Signs

• Fever and/or chills
• Cough or Barking Cough (Croup)
• Shortness of Breath
• Sore Throat or Difficulty Swallowing
• Decrease or Loss of Smell or Taste
• Runny or Stuffy/Congested Nose
• Headache
• Digestive Issues like Nausea/Vomiting, Diarrhea, Stomach Pain
• Extreme Tiredness or Muscle Aches
• Falling Down Often (18+ only)
• Pink Eye (18+ only)

Information Collection Notice

The personal information on this form is collected under the authority of the Municipal Act, 2001, S.O. 2001, c. 25. The information will be used and/or disclosed in the administration, processing. Questions about this collection can be directed to the Manager, Water and Wastewater, Community Services, 225 East Beaver Creek Road, Richmond Hill Ontario L4B 3P4, by telephone at 905-771-8800.