Please review the information below:

Are you currently experiencing any of these symptoms?

1. Fever or chills
2. Cough, croup ( squeaky or whistling nose when breathing), severe difficulty breathing or shortness of breath
3. Sore throat, hoarse voice or difficulty swallowing
4. Stuffy, congested or runny nose
5. Severe chest pains
6. Loss of consciousness
7. Feeling confused or unsure of where you are
8. Not feeling well
9. Falling down often
10. Fatigue* that is unusual, lack of energy or sluggishness
11. Muscle aches or joint pain* that is unusual or long lasting
12. Headache* that is unusual or long lasting
13. Pink eye
14. Decrease in or loss of smell or taste
15. Lack of appetite
16. Digestive issues (nausea/vomiting, diarrhea or stomach pain)

[If you have any of these symptoms – Please choose Disagree]

In the last 10 days, have you tested positive on a COVID-19 rapid antigen test, a self-testing kit or have been tested and are awaiting results? [If you have tested Positive – Please choose Disagree]

Have you been directed by Public Health, a physician or other healthcare professional to self-isolate for a period of time including today? [If you have been directed to stay home – Please choose Disagree]

In the last 14 days, have you had close contact* with someone who has or is suspected of having COVID-19 (including exhibiting any of the listed symptoms** and/or awaiting test results)? [If you have been in close contact with someone who has has or suspected of having Covid 19 – Please choose Disagree]

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If you have none of the symptoms above and all of the statements are FALSE, please choose Agree.

If you have one or more of the symptoms above or one of the statements are TRUE, please choose Disagree.