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MBB COVID-19 Visitor Questionnaire and Consent新冠肺炎访客问卷和同意书
To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce and visitors, we ask that you complete a simple questionnaire and a consent form. Your participation is important to help us take precautionary measures to protect you and everyone in the office. Thank you for your time.
为防止新冠肺炎传播并减少我们员工和访客的潜在风险, 请填寫以下简单的问卷和同意书。您的参与将帮助我们采取预防措施以确保您和员工的健康。感谢您的时间。
Your Name 姓名 *
Phone Number 电话号码 *
Email 电邮 *
Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing) ?在过去的14天内, 您是否曾经出现过任何感冒或类似流感的症状 (包括发烧,咳嗽,喉咙痛,呼吸系统疾病, 呼吸困难)? *
Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?在过去的14天内, 您是否与新冠肺炎确诊者有过密切接触? *
Have you travelled outside of Canada or have had close contact with anyone who has travelled outside of Canada in the last 14 days?在过去14天内,您曾否离开加拿大或曾与离开加拿大的任何人有密切接触? *
I/We will wear a mask when entering MBB office and remain wearing the mask(s) during the meeting. 我/我们进入MBB办公室时将戴上口罩,并会在会议期间一直戴着口罩。 *
Required
If I/We are later diagnosed as having Covid-19 within 14 days after visiting MBB, then I/We will contact MBB office immediately, so that MBB office may notify all potential persons at risk, and take necessary precautions to protect the health and well-being of all parties. 如我/我们在未来14天内被确诊为新冠肺炎患者, 我/我们将立即联系MBB, 以便MBB可以通知所有潜在危险的人士, 并采取必要的预防措施来确保各方的健康。 *
Required
Date of Appointment 到访日期 *
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