EMPLOYEE: COVID-19 HEALTH SURVEY

Name
Today's Date

1. Do you have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose? *

2. Have you returned to Canada from outside the country (including USA) in the past fourteen (14) days? *

3. In the past 14 days, did you have close contact with a person who has a probable or confirmed case of COVID-19? *

4. In the past 14 days, did you have close contact with a person who had an acute respiratory illness that started within 14 days of their close contact to someone with a probable or confirmed case of COVID-19? *

5. In the past 14 days, did you have close contact with a person who had an acute respiratory illness who returned from travel outside of Canada in the 14 days before they became sick? *

6. In the past 14 days, did you have a laboratory exposure to biological material (i.e. primary clinical specimens, virus culture isolates) known to contain COVID-19? *

I hereby declare that the information provided is true and correct. *
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