COVID-19 Prescreening Form

This form was drafted as one option for Travel Committee to consider for a short time.  It is currently set to send all completed forms to Wendy Hake (trial use). This notice will be be removed after that time. 

This prescreening form is stored in the WordPress DIVI library. 


COVID-19 Prescreening

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.

Symptoms (check any which apply)

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

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

In the last 14 days, have you or anyone you live with travelled outside of Canada? If exempt from quarantine requirements (for example, an essential worker who crosses the Canada-US border regularly for work), select “No.”

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing.

In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?

In the last 10 days, have you tested positive for COVID-19?

10 + 4 =

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