Ontario Coronavirus (COVID-19) Self-Assessment
Please complete this survey truthfully to the best of your knowledge.

Please note that by filling this out you agree that your name and contact information may be shared with the Thunder Bay District Health Unit for COVID-19 contact tracing purposes.

If you answer yes to any of these questions it is encouraged to self-isolate for 14 days and get tested to protect yourself and others (survey taken directly from: https://covid-19.ontario.ca/self-assessment/).

Information to stay safe: https://www.ontario.ca/page/covid-19-stop-spread

Personal information is collected for the purpose of complying with provincial orders related to the COVID-19 pandemic. None of your personal information will be shared, rented, sold or otherwise released to any third party without your consent.

Any questions about this collection should be directed to: tblg@tblg.org.
Today's Date *
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What is your full name? *
What is your phone number? (email too if it's an easy way to contact you) *
Are you currently experiencing any of these issues? Call 911 if you are: *
Choose any/all that apply
Required
Are you currently experiencing any of these symptoms? *
Choose any/all that are new and not related to seasonal allergies or pre-existing medical conditions
Required
In the last 14 days, have you been in close physical contact with someone who tested positive for Covid-19? *
Close physical contact means being less than 2 metres away in the same room, workspace, or area, or living in the same home.
In the last 14 days, have you been in close physical contact with someone who is currently sick with new Covid-19 symptoms? *
Symptoms may include cough, fever, or difficulty breathing
In the last 14 days, have you been in close physical contact with someone who has returned from outside Canada with new Covid-19 symptoms? *
Symptoms may include cough, fever, or difficulty breathing
Have you traveled outside of Canada in the last 14 days? *
This does not include essential workers who cross the Canada-US border regularly
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