COVID-19 Screening Questionnaire

Please fill-up the form. All fields are required.
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Staff/Visitor Name

Visitor Contact Number

Visitor Email Address

1. Are you exhibiting any of the following symptoms?

Fever or chills

Difficulty breathing or shortness of breath

Cough

Sore throat, trouble swallowing

Runny nose/stuffy nose or nasal congestion

Decrease or loss of smell or taste

Nausea, vomiting, diarrhea, abdominal pain

Not feeling well, extreme tiredness, sore muscles

2. Have you travelled outside of Canada in the past 14 days?

3. Have you had close contact with a confirmed or probable case of COVID-19?

4. Have you or has anyone in your household tested positive for COVID-19 in the past 2 weeks?

4. Have you recently been tested for COVID-19 and are awaiting test results?

Signature

Date