PLEASE SUBMIT THIS FORM AS SOON AS POSSIBLE EACH MORNING WITH A YES OR NO ANSWER

First Name

Last Name

Do you have the following symptoms

Yes

Fevers and or chills

Cough or barking cough (croup)

Shortness of breath

Sore throat

Difficulty swallowing

Decrease or loss of smell or taste

Pink eye

Runny or stuffy/congested nose

Headache

Digestive issues like nausea/vomiting, diarrhea, stomach pain

Muscle aches

Extreme tiredness

Fall down often

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

Yes

In the past 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?

Yes

In the past 14 days, have you travelled outside of Canada? If you are exempted from federal quarantine as per Group Exemptions Quarantine Requirements under the Quarantine Act, select “No”.

Yes

Today's Date

I declare that the info I’ve provided is accurate & complete

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