Name *

First Name

Last Name

Contact Phone *

(###)

###

####

1. Do you have any of the following symptoms: fever, cough, difficulty breathing, muscle aches, fatigue, headache, sore throat, runny nose, lethargy? *

yes

no

2. Have you been in contact with anyone experiencing the above symptoms? *

yes

no

3. In the last 14 days, have you been diagnosed with COVID-19 or been in contact with someone that is confirmed to have COVID-19? *

yes

no

4. Have you returned from any travel outside of BC in the last 14 days? *

yes

no