NLL Covid 19 Screening Form
Screening must be completed by all participants prior to each new event date .
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Participant's Last Name *
Participant's First Name *
Date of Activity *
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Do you have a fever? *
Have you had any of the following symptoms in the last 14 days? Cough, shortness of breath, difficulty breathing, runny nose, sore throat, difficulty swallowing, loss of sense of smell or taste, unusual fatigue, nausea or vomitting, unusual headache, loss of appetite, muscle or joint pain, feeling unwell. *
Have you, or anyone in your household, been outside of Canada in the last 14 days? *
Have you, or anyone in your household, been in close contact with someone who is ill with a coughand/or fever in the last 14 days? *
Have you, or anyone in your household, been in close contact with someone who is potentiallyexposed to COVID-19, or has a confirmed case of COVID-19? *
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