COVID-19 Self Screening Questionnaire Step 1 of 4 25% Due to the COVID-19 pandemic, health & safety precautions require you to complete daily screening questions to assess your fitness to enter the building. All visitors MUST complete the screening questionnaire within 2 hours before entering the building. First Name(Required) Last Name(Required) Email(Required) PhoneWe require your email address in the event of a COVID positive exposure at SLD. Staff will notify you if this does occur.Are you fully vaccinated?(Required) Yes No SLD Contact(Required)Amanda OlfatiBeverly WellsBryan LueDerek PetridisDevon RoseDiane MullaneJo-Ann YoungJP LacroixJulia MorganKevin ChanLing LiLori SmaleMelinda DeinesMurtuza KitabiRichard DirsteinTom Dimoff Please confirm that you are NOT presenting any of the following symptoms of COVID-19: • Shortness of breath and/or difficulty breathing • Cough • Fever (usually 38 degrees or higher) • Chills • Repeated shaking with chills • Muscle pain • Headache • Sore Throat • New loss of taste or smell(Required) I confirm that I am NOT presenting any of the symptoms of COVID-19 identified by Provincial Health Services I am presenting some of the symptoms of COVID-19 identified by Provincial Health Services In the last 14 days have you:Been in contact with someone who was diagnosed with COVID-19?(Required) YES NO Been in close contact with someone who had COVID-19 symptoms ?(Required) YES NO Travelled internationally or taken a cruise(Required) YES NO On returning to Canada what were the results of your COVID test?(Required) Received a negative COVID test on return Received a negative COVID test on return / I am fully vaccinated. Did not do a COVID test on my return I tested positive for COVID NameThis field is for validation purposes and should be left unchanged.