Covid-19 Screening

Staff/ Visitor Name*:

Visitor Email Address*:

Visitor Contact Number*:

Please indicate which symptoms you are experiencing*:

Fever or chills
Difficult 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

Have you travelled outside of Canada in the past 14 days?*:

Yes No

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

Yes No

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

Yes No

Have you recently been tested for COVID-19 and are awaiting test results?*:

Yes No

Security Question:

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *:

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Covid-19 Screening

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