Covid 19 - Attestation

Seaway Mall

Name:
Enter either of the following contact methods:
Email:
CellPhone:
COVID-19 Signs and Symptoms:
Fever / chills, new cough or a cough that is getting worse, loss of (or change in) taste or smell, shortness of breath (while sitting or walking at a regular pace), sore throat, runny nose / nasal congestion, unusual level of fatigue, unusual headache, nausea / vomiting, diarrhea, loss of appetite, feeling unwell for an unknown reason.
1. Do you have any of the symptoms listed above?


2. In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19 or have received a Covid Alert exposure notification on your cell phone?*


3. Have you been told you that you should currently be isolating (staying at home)?*


4. In the last 14 days, have you anyone you live with travelled outside of Canada?*


5. Is anyone in your household currently experiencing any new Covid-19 symptoms and/or waiting for test results after experiencing symptoms?*