• Date
    MM slash DD slash YYYY
  • Patch
  • 1. Do you have any new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions. Fever 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, abdominal pain, not feeling well, extreme tiredness, sore muscles?
  • 2. Have you had close contact with a confirmed or probable case of COVID-19?
  • I certify that all information I have provided is true.
  • If the individual answers YES to either question, they have not passed and can not perform work. They should isolate immediately and complete the Ontario self assessment at . Please advise of results. Worker antigen rapid testing is available upon request.
  • This field is for validation purposes and should be left unchanged.