Pre-screening Questionnaire for COVID-19 For Program Participants
Awaken Souls and Toronto City Mission
Sign in to Google to save your progress. Learn more
Name (English / Chinese) 姓名 (請用證件內姓名): (英文 / 中文): *
Gender 性別 *
Programs/ Activities 參加課程/活動名稱: *
Contact Phone No 聯絡電話號碼 *
Your email 電郵地址 *
1. How old are you? 你的年齡 *
2. For the past 14 days, do you have any of the following symptoms: fever, dry cough, running nose, sore throat, and shortness of breath, difficulty swallowing, headaches, body aches, muscle or joint pain, digestive issues like nausea/ vomiting, diarrhea, stomach pain, loss of taste and/or smell, pink eye, loss appetite, fatigue, falling down often (for older people) or any other symptoms? 在過去十四天,你是否有以下任何症狀:發燒、咳嗽、呼吸道感染症狀、喉嚨痛、呼吸急促、吞嚥困難、頭痛、身體疼痛、肌肉或關節疼痛、作嘔、腹瀉、嘔吐、喪失味覺和/或氣味、紅眼症、食慾不振、疲勞、常跌倒(長者)等或其他症狀? *
3. To the best of your knowledge, have you or anyone in your household have been in close proximity to any individual who tested positive for COVID-19? 據你所知,你或你家庭中的任何人在過去14天內是否曾與COVID-19檢測呈陽性的任何人接觸? *
4. Have you or anyone in your household traveled outside Canada in the past 14 days? 你或你家庭中的任何人在過去14天內是否從外地到達加拿大? *
5. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? 你的醫生、健康服務提供者、公共醫療部門建議你現在應留在家中隔離 ? *
6. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? 在過去十四天, 你的手提電話有否收過COVID 警報提示訊息? *
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy