Covid-19 Health Check | My Site

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MANDATORY ANNUAL WAIVER

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

My body temperature is lower than 98.6°F/ 37.5°.

I am not experiencing any of these symptoms: fever, chills, cough, sore throat, shortness of breath, loss of taste, runny nose, pink eye, headache, nausea, headache, muscle aches or extreme tiredness

In the last 14 days I have not been in close contact with a Covid-19 patient, travelled outside canada, received an alert that I have been in close contact with a person with covid-19.

I am not living with anyone who is currently experiencing covid-19 symptoms or waiting for test results after experiencing symptoms, been told to self isolate.

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

2429 Golf Course Rd, Newcastle, ON L1B 1L9