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COVID
COVID-19 QUESTIONNAIRE
Name
First
Last
Current Time
*
:
HH
MM
AM
PM
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?
Have you travelled outside of Canada in the past 14 days?
*
NO, I have NOT travelled outside of Canada
YES, I have travelled outside of Canada
DUE TO YOUR ANSWERS, YOU WILL
NOT
be permitted to enter the Factory. Please call 519-748-9003 to discuss.
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