CLBC COVID-19 Health Declaration Form
* Details of this health declaration will be kept in record securely by CLBC to help support contact tracing, as per Toronto Public Health guidance.
* 跟據多市衞生部指引,教會將小心保存已提交健康申報表,以支援衞生部在有需要下聯絡出席者。

* The Form is to be filled out on the same day prior to every meeting, at most two hours in advance.
* 申報表應在參加聚會當日最多兩小時前提交。

* Anyone with even one symptom of COVID-19 should get tested and stay home.
* 如肢體有任何一種 COVID-19 徴狀,請留在家中。
Attention: Please follow the sequence to enter Last name and First name. Please also use the last name from your household. This sequence helps us to sort name list. 留意:請跟從姓名填寫次序,也留意使用你家庭姓氏。這次序幫助我們排列名單。
Last name, First name 姓名 *
Date 日期 *
MM
/
DD
/
YYYY
Church meeting going to join 計劃參加的教會聚會 *
Do you have any of the following 你是否有以下徴狀:
Fever (A fever is a temperature of 37.8C or greater) 發熱(體溫在 37.8C 或以上為發熱) *
Cough 咳嗽 *
Difficulty breathing 呼吸困難 *
Sore throat, trouble swallowing 喉嚨痛, 吞嚥困難 *
Runny nose 流鼻水 *
Loss of taste or smell 失去味覺或嗅覺 *
Not feeling well 身體不適 *
Nausea, vomiting, diarrhea 噁心, 嘔吐, 腹瀉 *
Have you been in close contact with someone who is sick or has confirmed COVID-19 in the past 14 days? 在過去 14 日內曾接觸確診病人或確診 COVID-19人仕? *
Have you returned from travel outside Canada in the past 14 days? 在過去 14 日從加拿大以外旅遊返回加國? *
If you answered “YES” to any of these questions, go home & self-isolate right away. Call Telehealth or your health care provider, to find out if you need a test. 如以上問題答案有“是”,請馬上留在家中自我隔離,並聯絡 Telehealth 或你的醫療支援服務以確定是否需要進行測試。
Attention: This form is to be filled out on the same day prior to every meeting, at most two hours in advance.
注意:申報表應在參加聚會當日最多兩小時前提交。
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