TTC COVID-19 Form

COVID-19 Screening Questions

Full Name *

Symptom and exposure screening questions (check all that apply)

A. Do you have a new onset, or worsening, of any ONE of the following symptoms? *

Fever > 38°C or subjective fever/ chills

Cough

Sore throat/ hoarse voice

Shortness of breath/ breathing difficulties

Loss of taste or smell

Vomiting or diarrhea for more than 24 hours

None of the above

If you have any one of the above symptoms, DO NOT ENTER THE INDOOR FACILTY.

B. Do you have a new onset, or worsening, of any TWO of the following symptoms? *

Runny nose

Muscle aches

Fatigue

Conjunctivitis (pink eye)

Headache

Skin rash of unknown cause

Nausea or loss of appetite

None of the above

If you have any two of the above symptoms, DO NOT ENTER THE INDOOR FACILTY. If you have only one symptom in section B and it has been less than 24 hours since it started, stay home and avoid contact with others

Exposure history *

1. Have you, or a member of your household, been in close contact (within 2 meters/ 6 feet for more than 10 minutes) in the last 14 days with a confirmed COVID-19 case or been in contact with anyone who is waiting for COVID-19 test result?

2. Have you been exposed to COVID-19 in a work or public setting?

3. Have you, or a member of your household, travelled outside of Canada or within Canada in the past 14 days AND have been advised to quarantine?

4. Is a member of your household sick with COVID-19 symptoms?

5. Are you, or a member of your household, waiting for COVID-19 testing results?

None of the above.

COVID-19 Screening Questions

Symptom and exposure screening questions (check all that apply)

If you have any one of the above symptoms, DO NOT ENTER THE INDOOR FACILTY.

If you have any two of the above symptoms, DO NOT ENTER THE INDOOR FACILTY. If you have only one symptom in section B and it has been less than 24 hours since it started, stay home and avoid contact with others

If you have exposure to any of the above, DO NOT ENTER THE INDOOR FACILITY.