Your Name
Your Company
Contact Phone Number
Fever or chills YesNo
Difficulty breathing or shortness of breath YesNo
Cough YesNo
Sore throat, trouble swallowing YesNo
Runny nose/stuffy nose or nasal congestion YesNo
Decrease or loss of smell or taste YesNo
Nausea, vomiting, diarrhea, abdominal pain YesNo
Not feeling well, extreme tiredness, sore muscles YesNo
YesNo
If you answered Yes to any of the questions listed above you MAY NOT ENTER the building. Go home to self-isolate immediately and contact your health care provider or Telehealth Ontario (1 866-797-0000) to find out if you need a COVID-19 test.