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Covid 19 Screener Form
First Name
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Last Name
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Email Address
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Have you or anyone in your household had close contact* with anyone with acute respiratory illness or travelled outside Canada in the past 14 days?
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Yes
No
Do you or anyone in your household have a confirmed case of COVID-19 (or test results pending+) or had close contact* with a confirmed case of COVID-19 not yet resolved (or test results pending+) without wearing appropriate PPE? *
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Yes
No
Do you have any of the following symptoms: fever, cough, shortness of breath or difficulty breathing, sore throat, difficulty swallowing, decrease or loss of smell or taste, chills, headaches, unexplained fatigue, muscle aches, nausea, vomiting, diarrhea, abdominal pain, pink eye, runny nose / congestion without other known cause.
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Yes
No
PLEASE CHECK EACH BOX BELOW TO ACKNOWLEDGE OUR POLICIES AND CERTIFY THAT THE INFORMATION YOU ARE SUBMITTING IS ACCURATE *
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I have reviewed the consent policy
I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge.
What is your role at Community Care for Central Hastings?
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Staff
Volunteer
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