COVID-19 Screening Name Email Phone 1. Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions. a. Fever and/or chills? YES NO b. Cough or barking cough (croup)? YES NO c. Shortness of breath? YES NO d. Decrease or loss of smell or taste? YES NO e. Fatigue, lethargy, malaise and/or myalgias YES NO f. Nausea, vomitting and /or diarrhea YES NO 2. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)? YES NO 3. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?This can be because of an outbreak or contact tracing. YES NO 4. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?If public health has advised you that you do not need to self-isolate (e.g., you are fully immunized* or have tested positive for COVID-19 in the last 90 days and since been cleared), select “No.” YES NO 5. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?If you have already gone for a test and got a negative result, select "No."If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No." YES NO 6. In the last 10 days, have you tested positive on a rapid antigen test or a homebased self-testing kit?If you have since tested negative on a lab-based PCR test, select “No.” YES NO 7. In the last 14 days, has someone in your household (someone you live with) travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements) in the last 14 days?If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.” YES NO 8. In the last 10 days, has someone in your household (someone you live with) been identified as a ”close contact” of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self-isolate in the last 10 days?If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.” YES NO 9. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”If you are fully vaccinated or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.” YES NO Send
