Your Name*

Today's Date

1. In the past 14 days, did you have close contact with a person who has a probable or confirmed case of COVID-19? *
YesNo

2. In the past 14 days, did you have close contact with a person who has a probable or
confirmed case of COVID-19? *
YesNo

3. In the past 14 days, did you have close contact with a person who has a probable or confirmed case of COVID-19? *
YesNo

4. In the past 14 days, did you have close contact with a person who had an acute respiratory illness that started within 14 days of their close contact to someone with a probable or confirmed case of COVID-19? *
YesNo

5. In the past 14 days, did you have close contact with a person who had an acute respiratory illness who returned from travel outside of Canada in the 14 days before they became sick? *
YesNo

6. In the past 14 days, did you have a laboratory exposure to biological material (i.e. primary clinical specimens, virus culture isolates) known to contain COVID-19? *
YesNo

I hereby declare that the information provided is true and correct.
Confirm *