Fall 2021: MZAC Toronto COVID-19 Health Disclosure Declaration
NOTE: Updated form as per new regulations from the Ontario government as of June 30, 2021.
Please complete one form per person.
Prior to entering 30 Pemican Court, please consider the health and safety of others. Access to the building will not be granted for anyone who has either not completed this form or has been unable to check all of the criteria listed below.
Thank you for your cooperation.
Contact phone number
Do you have any of the following new or worsening symptoms or signs? (Check all that apply) Symptoms should not be chronic or related to other know causes or conditions:
Fever or chills
Difficulty breathing or shortness of breath
Sore throat, trouble swallowing
Runny nose/stuffy nose or nasal congestion
Decrease or loss of smell or taste
Nausea, vomiting, diarrhea, abdominal pain
Not feeling well, extreme tiredness, sore muscles
Additional screening questions:
I have not travelled anywhere outside of Canada, or have been in contact with anyone who has travelled outside of Canada in the last 14 days.
I have not had close contact with a confirmed or probable positive COVID-19 test result
I do not have a pending COVID-19 test result
Send me a copy of my responses.
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