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: 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: ed@hnliteracy.com
Which Adult Learning Centre is your appointment at? *
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? *
Time
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Today's date: *
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Are you currently experiencing any of these issues? Call 911 if you are: *
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? *
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