COVID Questionnaire

COVID-19 Screening Tool

* Indicates required field

Name *

First

Last

Email *

1. Are you experiencing any of the following symptoms with unknown cause: fever, cough, shortness of breath, sore throat or runny nose?

Choose One *

Yes NO

2. Have you had contact with any person with, or under investigation for, COVID-19 in the last 14 days?

Choose One *

Yes No

3. Have you or anyone from your immediate household travelled outside of Canada in the past 14 days (for non-essential travel)?

CHOOSE ONE *

Yes No

4. Have you been require to quarantine or isolate by your public health authority within the past 10-14 days?

Choose One *

Yes No

Submit