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* 1. Enter Date

Date

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* 2. Name

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* 3. Contact Info

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* 4. What department or individual are you visiting today?

COVID-19 Symptoms Include:
- Fever
- Cough
- Difficulty breathing
- Sore throat, trouble swallowing
- Runny nose
- Loss of taste or smell
- Not feeling well
- Nausea, vomiting, diarrhea

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* 5. Do you have new or worsening (not including pre-disposed conditions) Symptoms of COVID-19?

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* 6. Have you travelled outside of Canada in the past 14 days?

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* 7. Have you had close contact with a confirmed or probable case of COVID-19?

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* 8. What building(s) do you have appointments in today? (Select all that apply)

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* 9. Confirm information accuracy.

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