NRN Covid-19 Screening

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Prior to our installers entering your home, you must complete our Covid-19 screening.

Full Name: *

Full Installation Address: *

Are you or anyone you are in close contact with experiencing any of the following symptoms of Covid-19: New Cough, Headache, Weakness, Fever, Difficulty breathing, Loss of smell or taste, Loss of appetite, or Chills. *

Yes

Have you or anyone you are in close contact with experienced any of above symptoms in the last 14 days? *

Yes

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

Yes

Do you provide care or have close contact with a person with Covid-19 (probable or confirmed case) while they were ill? *

Yes

Have you recently travelled to a Covid-19 hotspot? *

Yes

Have you or anyone you are in close contact with been advised by a health care provider to self isolate? *

Yes

Have you or anyone you are in close contact with visited or are employed in any long-term care facility *

Yes

Are you willing to wear a mask and practice social distancing from our installer for the duration of time that he or she is present at your location? *

Yes

Please be advised that if any of your answers indicate that you may have or have been in contact with a person with Covid-19 your install will have to be rescheduled. *

I understand the above statement

I do not understand the above statement

Required

I have read and understand all of the above questions and have answered them truthfully. *

Yes.

Required

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms