Symptom Attestation Question Title * 1. Are you experiencing any of the following symptoms? Click any that apply. A new fever (100.4 F or higher) or a sense of having a fever? A new cough that you cannot attribute to another health condition? New shortness of breath that you cannot attribute to another health condition? A new sore throat that you cannot attribute to another health condition? New muscle pain that you cannot attribute to another health condition or that may have been caused by a specific activity, such as physical exercise? New gastrointestinal symptoms, such as nausea, vomiting or diarrhea that you cannot attribute to another health condition? New respiratory symptoms, such as a runny nose, that you cannot attribute to another health condition? New chills that you cannot attribute to another health condition? New loss of taste or smell that you cannot attribute to another health condition? A new headache that you cannot attribute to another health condition or emotional reason? Difficulty swallowing? Runny nose (not related to seasonal allergies or other known causes or conditions? Pink eye (conjunctivitis) Falling down often? I am not experiencing any of the above symptoms. Question Title * 2. I attest that prior to coming onto the campus for working or learning purposes that I will conduct a self-check using the above list and that should I have one or more of the above symptoms I will follow the guidance from the Ontario Governments website. https://covid-19.ontario.ca/self-assessment/ Yes No Question Title * 3. I understand that if I am sick or have one or more of the above symptoms that I must stay home or leave the NOSM campus at which I am working and follow my Supervisor’s guidance for reporting illness or requesting to work from home. In addition, I will contact my health care provider for medical guidance and follow the guidance from the Ontario Governments website. Yes No Question Title * 4. If within the past 14 days you were in close contact with a person who has a COVID-19 infection, stay home and follow the guidance from the COVID 19 Ontario Self-Assessment tool. https://covid-19.ontario.ca/self-assessment/ Close contact includes being within approximately 6 feet of a person with confirmed COVID-19 for more than a few minutes, living with a person who has COVID-19 or having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on, sharing utensils). Question Title * 5. My name is: Question Title * 6. I work or learn in the following area: Administration and Operational Support Faculty Affairs Research & Library Office of the Dean and CEO Office of the Vice Dean Academic Continuing Education & Professional Development Undergraduate Medical Education Post Graduate Medical Education Health Sciences / NODIP Done
