PASP COVID-19 Screening Form

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Record of Contact Tracing & Covid-19 Symptom Screening

Email *

Name *

Phone: *

Date: *

YYYY

Time: *

Time

Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions. Check all that apply. *

Fever or chills

Difficulty 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

None of the above

Required

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

Yes

Required

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

Yes

Required

If you answered “Yes” to any of the questions above, please kindly leave the building. The Government of Ontario recommends that you self-isolate and contact your health care provider or Telehealth Ontario at 1-866-797-0000. Thank you for your cooperation.

Note that all information gathered on this document will remain confidential and is for tracing purposes only.

Thank you.

Once you receive your completion email, please forward to kits@mbot.com.

A copy of your responses will be emailed to the address you provided.

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