COVID-19 HEALTH & SAFETY QUESTIONNAIRE

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COVID-19 Health & Safety Questionaire

Have you had a Cough, Fever and/or chills, Shortness of breath, Sore throat, Difficulty swallowing, Runny or Congested nose, Decrease or loss of taste or smell, Pink eye, Headache, Digestive Issues, Muscle aches. Extreme tiredness or flu-like symptoms in the last 14 days?*

Yes None of the Above

In the last 14 days, have you travelled outside or within Canada and required to Quarantine by ArriveCAN?*

Yes No

If you are exempt from quarantine requirements (for example, an essential worker who crosses the Canada-US border regularly for work), select “No.”

In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?*

Yes No

Has a doctor, health care provider, or public health unit told you that you should currently be in Quarantine?*

Yes No

This can be because of an outbreak, contact tracing, or if you have tested positive.

I understand that I am required to wear a mask during my service unless instructed by my Esthetician.*

Yes No

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