1. Your Full Name*

2. Your Student # (if applicable)

3. Do you have any of the following symptoms?*
Fever, chills, cough or worsening of chronic cough, shortness of breath, sore throat, runny/stuffy nose, loss of sense of smell or taste, headache, fatigue, diarrhea, loss of appetite, nausea and vomiting, muscle aches, conjunctivitis (pink eye), dizziness or confusion, abdominal pain, skin rashes or discoloration of fingers or toes.
YesNo

4. Have you or anyone in your household returned from travel outside of Canada in the last 14 days?*
YesNo

5. Are you or is anyone in your household a confirmed contact of a person confirmed to have COVID-19?*
YesNo