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Office Screening Questionnaire
Please complete this form if you are planning to visit the office. Please note a mask is mandatory in all common areas of the office and building.
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* Indicates required question
Full name
*
Your answer
Phone number (for contact tracing purposes only)
*
Your answer
What date will you be visiting the office?
*
MM
/
DD
/
YYYY
Please select a time frame to which you expect to arrive
*
9am - 11am
11am -1pm
1pm-3pm
3pm-5pm
Required
Are you experiencing any of the following symptoms?
Sore throat
*
Yes
No
Vomiting
*
Yes
No
Nausea
*
Yes
No
Runny nose
*
Yes
No
Fever
*
Yes
No
Cough
*
Yes
No
Difficulty breathing or shortness of breath
*
Yes
No
Have you travelled outside of Canada in the past 14 days, or been in close contact with someone who has travelled outside of Canada in the past 14 days?
*
Yes
No
Have you been in close contact with someone who has a confirmed or probable case of COVID 19 in the last 14 days?
*
Yes
No
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