COVID Contract Tracing

COVID Questionnaire

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our clients, staff, and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time.

Please complete the fields below


1. Have you had a positive test for COVID-19 within the last 14 days?

2. Have you returned from any country outside Canada within the last 14 days?

3. Have you had close contact with, or cared for someone with a respiratory illness, or someone diagnosed with COVID-19 within the last 14 days?

4. Have you been in close contact with (closer than 6 feet and/or longer than 15 minutes) anyone who has traveled outside Canada within the last 14 days?

5. Have you experienced any flu-like symptoms in the last 14 days? o Cough o Shortness of Breath/Difficulty Breathing o Fever o Sore throat o Unexpected fatigue o Chills o Headache o Runny nose/nasal congestion o Muscle/body aches o Difficulty Swallowing o Disorders of taste or sense of smell o Nausea/vomiting/diarrhea

6. Do you agree that you have answered everything in this questionnaire honestly?

If you answered “yes” to any of the questions from 1 - 5, for everyone's safety, you will be required to reschedule your visit for another date. You are also advised to follow up with your doctor.

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