Required Screening Questions

1. 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.

• Fever or chills Yes No
• Difficulty breathing or shortness of breath Yes No
• Cough Yes No
• Sore throat, trouble swallowing Yes No
• Runny nose/stuffy nose or nasal congestion Yes No
• Decrease or loss of smell or taste Yes No
• Nausea, vomiting, diarrhea, abdominal pain Yes No
• Not feeling well, extreme tiredness, sore muscles Yes No

2. Have you travelled outside of Canada in the past 14 days? Yes No

3. Have you had close contact with a confirmed or probable case of COVID-19? Yes No

Name:

Contact # or email:

Please Select Dispatch Recipient Brandon Frank Jim Luke Mark Dowton Pat Bourgeois Parker Locke Stephen Abbott Ted