Name
Required
Phone Number
Required
Did you travel outside of Canada in the past 14 days?
Required
Yes
No
Have you tested positive for COVID-19 OR had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
Required
Yes
No
Do you have any of the following symptoms: Fever, New onset of cough, Worsening chronic cough, Shortness of breath, Difficulty breathing, Sore throat, Difficulty swallowing, Decrease or loss of sense of taste/smell, Chills, Headaches, Unexplained fatigue
Required
Yes
No
