COVID 19 SELF-SCREENING ATTESTATION
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PLEASE ANSWER THE FOLLOWING QUESTIONS

NO

YES
1. Do you have a cough, fever, sore throat, difficulty breathing or any other new or worsening symptoms?

NO

YES
2. Have you travelled outside of Canada in the past 14 days?

NO

YES
3. Have you had close contact with a person with acute respiratory illness who has travelled anywhere outside of Canada within the last 14 days before their illness?

NO

YES
4. Have you been in close contact with a confirmed or probable case of COVID-19 in the past 14 days?
If you answer YES to any of the above questions, or are in doubt, contact your health care provider for advice.
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Visit niagararegion.ca/health for
up-to-date COVID-19 information.