CLBC COVID-19 Health Declaration Form Adult
* Details of this health declaration will be kept in record securely by CLBC to help support contact tracing, as per Toronto Public Health guidance.
* 跟據多市衞生部指引，教會將小心保存已提交健康申報表，以支援衞生部在有需要下聯絡出席者。

* The Form is to be filled out on the same day prior to every meeting, at most two hours in advance.
* 申報表應在參加聚會當日最多兩小時前提交。

* Anyone with even one symptom of COVID-19 should get tested and stay home.
* 如肢體有任何一種 COVID-19 徴狀，請留在家中。
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Attention: Please follow the sequence to enter Last name and First name.  Please also use the last name from your household.  This sequence helps us to sort name list.  留意：請跟從姓名填寫次序，也留意使用你家庭姓氏。這次序幫助我們排列名單。
Last name, First name　姓名 *
Date　日期 *
MM
/
DD
/
YYYY
Do you have any of the following new or worsening symptoms:　您是否有以下任何新的或惡化的症狀:
» Fever (A fever is a temperature of 37.8C or greater) or chills 發熱（體溫在 37.8C 或以上為發熱) 或發冷
» Cough 咳嗽
» Trouble breathing 呼吸困難
» Decrease or loss of taste or smell 失去味覺或嗅覺
» Very tired, sore muscles or joints 非常疲倦，肌肉或關節酸痛
If you have an existing health condition that gives you the symptoms, answer “No”. If the symptom is new, different or getting worse, answer “Yes”.  如果您現有的健康狀況導致您出現這些症狀，請回答“否”。 如果症狀是新的、不同的或惡化的，請回答“是”。
If mild tiredness, sore muscles or joints occur within 48 hours after getting a COVID-19 vaccine, select “No” and continue to follow all public health measures.  If symptoms last longer than 48 hours or worsen, select “Yes”.  如果在接種 COVID-19 疫苗後 48 小時內出現輕度疲倦、肌肉或關節酸痛，請回答“否”並繼續遵循所有公共衛生措施。如果症狀持續時間超過 48 小時或惡化，請回答“是”。
If you are sick or have any symptoms of illness, including those not listed above, stay home and seek assessment from your health care provider if needed.  如果您生病或有任何疾病症狀，包括上面未列出的症狀，請留在家中並在需要時向您的醫療保健提供者尋求評估。
Does anyone in your household have one or more of the above symptoms and/or are waiting for test results after experiencing symptoms? 您家中是否有人有上述一種或多種症狀和/或在出現症狀後正在等待檢測結果？
• If you are fully vaccinated, answer “No.” 如果您已完全接種疫苗，請回答「否」。
• If the household member’s mild headache, tiredness, sore muscles or joints occurred within 48 hours after
 getting a COVID-19 vaccine, answer “No”. If their symptoms last longer than 48 hours or worsen, answer “Yes.” 如果家庭成員在接種 COVID-19 疫苗後 48 小時內出現輕度頭痛、疲倦、肌肉或關節酸痛，請回答「否」。 如果他們的症狀持續時間超過 48 小時或惡化，請回答「是」。
Have you been notified as a close contact of someone with COVID-19 or been told to stay home and self-isolate? 您是否被告知與 COVID-19 患者有密切接觸或被告知待在家裡並自我隔離？
 • If you are fully vaccinated and have not been advised to self-isolate by public health, answer “No.” 如果您已完全接種疫苗且公共衛生部門未建議您進行自我隔離，請回答「否」。
In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? 在過去 10 天內，您是否在快速抗原檢測或家庭自檢試劑盒中檢測呈陽性？
• If you have since tested negative on a lab-based PCR test, answer “No.” 如果此後您在實驗室的 PCR 測試中檢測結果為陰性，請回答「否」。
In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements? 在過去的 14 天內，您是否曾在加拿大境外旅行並被建議按照聯邦檢疫要求進行檢疫？
If you answered “YES” to any of these questions, go home & self-isolate right away.  Call Telehealth or your health care provider, to find out if you need a test.  如以上問題答案有“是”，請馬上留在家中自我隔離，並聯絡 Telehealth 或你的醫療支援服務以確定是否需要進行測試。
I confirm that I do not have any symptom or situation mentioned above. 本人確認沒有以上病徵或情況。 *
Required
Attention: This form is to be filled out on the same day prior to every meeting, at most two hours in advance.
注意：申報表應在參加聚會當日最多兩小時前提交。
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