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* 1. First and Last Name

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* 2. Supervisor Name

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* 3. Branch Location

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* 4. Do any of the circumstances below apply to you?

(Please note, "close contact" refers to being within 2 metres for a prolonged period of time, living with, caring for, being in a relationship with, etc.)

a) Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.

- Fever or chills ( Temperature of 37.8 degrees Celsius)
- Shortness of breath
- Cough or barking cough (croup)
- Sore throat
-Difficulty swallowing
- Runny nose/stuffy nose or nasal congestion
- Decrease or loss of smell or taste
- Digestive issues with nausea/vomiting, diarrhea, stomach pain
- Extreme tiredness
- Muscle aches
- Pink eye (Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have) 
- Headache (Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)
- Falling down often

b) In the last 14 days, have you or anyone you live with travelled outside of Canada?

c) In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19? (Please note, “close contact” refers to being within 2 metres for a prolonged period of time, living with, caring for, being in a relationship with, etc.)

d) Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

e) Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

f) In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?

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* 5. Terms and Conditions

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