SKS COVID Self Assessment
If you answer yes to any of the following questions, please do not enter the building. For employees, please follow the SKS COVID Illness procedure.
Sign in to Google to save your progress. Learn more
Date *
MM
/
DD
/
YYYY
Full Name (including business name & address if applicable) *
Location *
Reason *
Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions. *
Yes
No
Fever or Chills?
Difficulty Breathing or shortness of breath?
Cough?
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?
Have you travelled outside of Canada in the last 14 days? *
Have you had close contact with a confirmed or probable case of COVID-19? *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy