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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?
*
Yes
No
2. Have you returned to Canada from outside the country (including USA) in the past fourteen (14) days?
*
Yes
No
3. In the past 14 days, did you have close contact with a person who has a probable or confirmed case of COVID-19?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
I hereby declare that the information provided is true and correct.
*
Confirm
Submit
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