COVID-19 Screening Form

• 
  First Name *
  Please leave this field empty.

• 
  Last Name *

• Date *
  

• Did you receive your final (or second) vaccination dose more than 14 days ago? *
  YesNo

If you answered "No" to the above question:
Did you travel outside of Canada in the past 14 days?Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

• Do you have any of the following symptoms? *
  Fever or chills?New onset cough or worsening chronic cough?Shortness of breath?Decrease or loss of sense of taste or smell?If adult >18 years of age: unexplained fatigue/lethargy/malaise/muscle aches (myalgias)?If child <18 years of age: nausea/ vomiting, diarrhea?None of the above

• Do you have a concern for a potential COVID-19 infection (e.g. is there an outbreak in the facility where you live, are you awaiting COVID-19 test results, etc)? *
  YesNo

• Have you tested positive for COVID-19 in the past 10 days or have they been told they should be isolating? *
  YesNo

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