disclosure declaration

COVID-19 Disclosure Declaration

1. Have you or anyone who resides in your home travelled outside of Canada in the last 30 days? *

2. Have you or anyone who resides in your home experienced any of the following symptoms over the last 14 days: fever, dry cough, shortness of breath or difficulty breathing? *

3. Have you or anyone who resides in your home been in contact with someone exhibiting the following symptoms over the last 14 days: fever, dry cough, shortness of breath or difficulty breathing? *

4. Have you or anyone who resides in your home had contact with anyone with a suspected or confirmed case of COVID-19 *

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© 2023 by Serena Ivy.