AIM Gymnastics Ajax - COVID-19 Self-Assessment Form
Email address *
Name: *
Today's date: *
MM
/
DD
/
YYYY
Temperature
Close physical contact means:
- Being less than 2 metres away in the same room, workspace, or area for over 15 minutes
- Living in the same house
Have you travelled outside of Ontario in the last 14 days? *
In the last 14 days, have you been in close physical contact with a person who is currently sick with a new cough, fever, or difficulty breathing? *
In the last 14 days, have you been in close physical contact with a person who returned from outside of Canada within the last 2 weeks? *
In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19? *
Are you in any of these at risk groups? Check all that apply. *
Required
Are you currently experiencing any of these issues? Call 911 if you are. Check all that apply. *
Required
Are you currently experiencing any of these symptoms? Check all that apply. *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Athletes In Motion Gymnastics. Report Abuse