1.Do you have any of the following worsening symptoms or signs?

FEVER OR CHILLS

COUGH

DIFFICULTY BREATHING OR SHORTNESS OF BREATH

SORE THROAT, TROUBLE SWALLOWING

RUNNY STUFFY NOSE

DECREASE OR LOST OF TASTE OR SMELL

NAUSEA, VOMITING, DIARRHEA

NOT FEELING WELL, EXTREME TIREDNESS, SORE MUSCLES

YES

NO

2.Have you had close contact with a confirmed or probable case of COVID-19 without wearing appropriate PPE?

Yes

No

3.Have you travelled outside Canada in the past 14 days?

Yes

No

4.What is your first and last name, email address and phone number?