Today's Date *

Date

Please enter your First Name *

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Please enter your Last Name *

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Do any of the following apply to you? *

☐I am fully vaccinated against COVID-19 (it has been 14 days or more since your final dose of either a two- dose or a one-dose vaccine series)

☐I have tested positive for COVID-19 in the last 90 days (and since been cleared by the local public health unit)

☐Neither of the above statements apply to me

Are you currently Experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions. *Fever and/or Chills *Cough or Barking cough (croup) * Shortness of Breath *Decrease or loss of smell or taste *(for adults 18+) Fatigue, lethargy, malaise and/or muscle aches/joint pain * (for children under 8 years) Nausea, vomiting and/or diarrhea *

☐Yes

☐No

In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)? *

☐Yes

☐No

Has a doctor, health care provider, or public health until told you that you should currently be isolating (staying at home)? *

☐Yes

☐No

In the last 10 days, have you been identified as a "close contact" of someone who currently has COVID-19? (If public health has advised you that you do not have to self-isolate, select "no") *

☐Yes

☐No

In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? *

☐Yes

☐No

In the last 10 days, have you received a COVID alert exposure notification on your cell phone? *

☐Yes

☐No

In the last 14 days, has someone in your household (someone you live with) travelled outside of Canada AND been advised to quarantine (as per federal quarantine requirements)? *

☐Yes

☐No

In the last 10 days, has someone in your household (someone you live with) been identified as a "close contact" of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self-isolate? *

☐Yes

☐No

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

☐Yes

☐No

Signature Required. By typing your name here, you agree that you have provided accurate and truthful answers to the best of your knowledge. Please type your First and Last Name below (Input order First/Last) *

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