Self-Screening for Signs of illness or Communicable Diseases 2021

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Full Name (i.e.First name and Last Name) *

Contact Phone No. *

Are you currently experiencing any of these symptoms? *

Fever and/or chills

Cough or barking cough (croup)

Shortness of breath

Decrease or loss of taste or smell

Muscle aches/joint pain

Extreme tiredness

NONE OF THE ABOVE

Required

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *

Yes

In the last 14 days, have you travelled outside of Canada and been told to quarantine (per the federal quarantine requirements)? *

Yes

In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19? *

Yes

Has a doctor, health care provider, or public health unit told you that you should currently be isolated(staying at home)? *

Yes

In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit? *

Yes

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