Ontario Coronavirus (COVID-19) Self-Assessment
Please complete this survey truthfully to the best of your knowledge.
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:
Information to stay safe:
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:
Which Adult Learning Centre is your appointment at?
London Adult Learning Centre
Haldimand Adult Learning Centre (Dunnville)
Norfolk Learning Centre (Simcoe)
Are you staff at this centre?
What is your full name?
What is your phone number? (email too if it's an easy way to contact you)
What time is your appointment at?
Are you currently experiencing any of these issues? Call 911 if you are:
Severe difficulty breathing (struggling for each breath, can only speak in single words)
Severe chest pain (constant tightness or crushing sensation)
Feeling confused or unsure of where you are
None of the above
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
Fever (feeling hot to the touch, a temperature of 37.8 degrees C/100.4 degrees F or higher)
Cough that's new or worsening (continuous, more than usual)
Barking cough, making a whistling noise when breathing (croup)
Shortness of breath (out of breath, unable to breathe deeply)
Sore throat (not related to seasonal allergies or other known causes or conditions)
Runny nose (not related to seasonal allergies or other known causes or conditions)
Stuffy or congested nose (not related to seasonal allergies or other known causes or conditions)
Pink eye (conjunctivitis)
Headache that's unusual or long lasting
Digestive issues like nausea/vomiting, diarrhea, stomach pain (not related to other known causes or conditions)
Muscle aches that are unusual or long lasting
Extreme tiredness that is unusual (fatigue, lack of energy)
Falling down often
None of the above
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?
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