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* 2. Your Information

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* 3. Today's Date

Date

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* 4. Is the student/child/staff/essential visitor currently experiencing any of these symptoms?

Fever and/or chills 

Cough or barking cough (croup) 

Shortness of breath 

Decrease or loss of taste or smell 

Sore throat or difficulty swallowing 

Runny or stuffy/congested nose 

Headache

Nausea, vomiting and/or diarrhea 

Extreme tiredness or muscle aches


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* 5. In the last 14 days, has the student/child/staff/essential visitor travelled outside of Canada?

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* 6. In the last 14 days, has the student/child/staff/essential visitor been Yes No
identified as a “close contact” of someone who currently has COVID-19?

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* 7. Has a doctor, health care provider or public health unit told you that the student/child/staff/essential visitor should currently be isolating (staying at home)?

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* 8. Has someone in the household travelled outside of Canada in the last 14 days
and are currently living within the home (i.e. are not isolating at a
government-funded isolation centre)?

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* 9. Has someone in the household been identified as a “close contact” of someone who currently has COVID-19?

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* 10. Has someone in the household been part of a dismissed school or child care cohort in the last 14 days, and are currently at home isolating?

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* 11. Is someone in the household sick with the COVID-19 symptoms outlined above
(new or worsening) and does not yet have a negative COVID-19
test result or alternative diagnosis from a health-care provider?

0 of 11 answered
 

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