Top Skill K9 - Covid-19 Assessment form Formulaire d'auto-évaluation Covid-19
complete and send this form before each class or training session, EOHU requirement
Complété et envoyé ce formulaire avant chaque classe ou entrainement, Requis par EOHU
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Email *
Today's date? *
MM
/
DD
/
YYYY
First name & Last name/ Nom & Prénom *
Do you have any of the following new or worsening symptoms? Est-ce que vous présentez nouvellement un de ses symptômes? *
Yes/Oui
No/Non
Fever,Chills / Fievre ou frisson
Cough/ toux
Difficulty breathing,Shortness of breath/ difficulte a respirer
Sore throat,difficulty swallowing/ mal de gorge
Running nose (unrelated to seasonal allergies)/ nez qui coule non relier a autre chose
Loss of taste or smell/ perte olfactive
Not feeling well, headaceh, unexplained tiredness and muscle aches/ vous ne vous sentez bien, fatigue,..
Nausea, vominiting, diarrhea, abdominal pain/ nause, vomissement, douleur abdominale
In the last 14 days, have you had close physical contact with a person who: was sick with a respiratory illness/ has return from travel outside of Canada in the last 14 days?/ was confirmed or probable case of Covid-19/ Dans les dernier 14 jours avez vous ete en close contact avec quelqu<un qui a recu un test covid-19 positif ou incertain
In the last 14 days, have you travelled outside of Canada/ Dans les 14 jours, avez-vous voyager endehors du Canada
Are you waiting for a result of COVID-19 Test or someone around you/ Etes-vous en attente d'un résultat de test covid-19 ou quelqu'un proche de vous?
Did you have received a positive Covid-19 test in the last 14 days/Avez-vous reçu en test Covid-19 positif dans les derniers 14 jours
Do you have someone from the same house with you in class?Only one Adulte or kid is allow(baby is not included as a guest) Avez-vous quelqu' un de la meme maison qui vous accompagne(un adulte par maison)(Bebe ne compte pas dans la personne qui accompagne)? *
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