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Covid-19 Health Declaration
How are you feeling today?
First Name
Last Name
Site Location
Company Name
In the past 14 days, at work or elsewhere, did you have close contact with someone who has a probable or confirmed case of COVID19?
Yes
No
Do you have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose?
Yes
No
Have you returned from outside the country (including Canada / USA) in the past 14 days or been directed by Public Health to self-isolate??
Yes
No
Date
I declare that the info I’ve provided is accurate & complete
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Submit
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