Name of Individuals (from the same household) *

First Name

Last Name

In the last 5 days, have you experienced any of the following new or worsening symptoms or signs (symptoms should not be chronic or related to other known causes or conditions): fever (over 37.8 C) or chills; difficulty breathing or shortness of breath; cough; sore throat, trouble swallowing; runny nose/stuffy nose or nasal congestion; decrease or loss of smell or taste; nausea, vomiting, diarrhea, extreme tiredness *

No

Yes

Have you travelled outside of Canada in the past 14 days and were told to quarantine? *

No

Yes

In the past 5 days, have you or had "close contact" with someone who has tested positive for COVID-19 or a probable case of COVID-19? *

No

Yes

Do you live with someone who is currently isolating because of COVID-19 symptoms, a positive COVID-19 test or waiting for the results of a COVID-19 test? *

No

Yes

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *

No

Yes