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?

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?

Have you returned from outside the country (including Canada / USA) in the past 14 days?

In the past 14 days have you been directed by Public Health to self-isolate?