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* 1. Employee Name:

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* 2. Date Completed:

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* 3. Are you experiencing any of the following symptoms?

  Yes No
Fever
New or worsening cough
Stuffy or runny nose
Sore throat or painful swallowing
Difficulty breathing
Diarrhea
Nausea and/or vomiting
Fatigue
Muscle aches
Loss of appetite
Chills
Headache
Loss of sense of smell

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* 4. Have you traveled outside of Canada - including the United States within the last 14 days?

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* 5. Have you been in close contact with someone who has COVID-19 within the last 14 days?

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* 6. Have you been in close contact with someone who has COVID symptoms within the last 14 days? (Cough, sneezing, runny nose, fever, sore throat, difficulty breathing, or episodes of vomiting and/or diarrhea).

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* 7. Have you been told to self-isolate in accordance with Public Health directives?

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