Covid Self-Assessment Form Name(required) Email(required) Phone Number(required) Name of Event or Host(required) Date of event(required) Do you have any of the following symptoms? If YES to any of the symptoms, please do not enter the facility and contact staff directly 1-800-716-7310.(required) Fever and/or chills Cough and/or shortness of breath Decrease or loss of sense of taste or smell Unexplained fatigue Muscle aches nausea/vomiting No symptoms Have you or someone you have been in contact with tested positive for COVID-19 in the past 14 days? If YES, please do not enter the facility and contact staff directly 1-800-716-7310.(required) Yes No Have you travelled outside of Canada in the past 14 days? If YES, please do not enter the facility and contact staff directly 1-800-716-7310.(required) Yes No Did you receive your final (or second) vaccination dose more than 14 days ago? *Answer will be required after September 22, 2021. If NO, please do not enter the facility and contact staff directly 1-800-716-7310.(required) Yes No Not disclosing Submit Δ
