COVID

COVID-19 QUESTIONNAIRE
Name
First Last
Current Time*

: HH

MM
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.

268 Trillium Drive, Kitchener

519-748-9003

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COVID-19 QUESTIONNAIRE