COVID-19 Questionnaire COVID-19 Mandatory Self-Screening Questionnaire All instructors and participants must self-screen with the following questionnaire prior to attending any course. By pressing submit, you declare that your answers are true to the best of your knowledge.Note:- Close contact is defined as less than 2 metres, for a prolonged period of time (ie. Living with, caring for, in a relationship with).- Unprotected is defined as not wearing the recommended personal protective equipment (gloves, masks).- If you answered 'Yes' to any of the questions, you will NOT be permitted to attend any courses offered by MedicAid. You should stay home and self monitor. You should also notify or seek medical attention if required. Name*FirstLast Date of Birth*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Have you tested positive for COVID-19?*YesNo Do you have any of the following symptoms? Check all that apply:(1)*FeverCoughShortness of Breath / Difficulty breathingNew Flu-like symptomsNew/unexplained feeling of fatigue, malaise, or confusionNew loss or change in ability to taste or smellChest painNausea, vomiting, and/or diarrheaOther _____________________None Have you travelled outside of Canada within the last 14 days?*YesNo Have you had close unprotected contact with a probably or confirmed COVID-19 case?*YesNo Have you had close unprotected contact with a person with acute respiratory illness who has been outside of Canada in the last 14 days?*YesNoSubmitReset
