STFC COVID-19 Screening Questionaire
To be completed 12 hours or less prior to arrival
Today's Date
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Year
-
Month
Day
Date
Name
First Name
Last Name
Phone Number
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Area Code
Phone Number
Do you have any of the following symptoms: fever/feverish, new or existing cough, difficulty breathing, sore throat, runny nose, nausea, vomiting, diarrhea, not feeling well?
Yes
No
Have you traveled internationally within the last 14 days (outside Canada)?
Yes
No
Have you had close contact with someone that has been ill or is a confirmed or probable COVID-19 case in the past 14 days?
Yes
No
Have you had close contact with a person with acute respiratory illness who has been outside Canada in the last 14 days?
Yes
No
Have you had a COVID-19 test?
Yes
No
If Yes, What was the date of your last COVID-19 test?
-
Month
-
Day
Year
Date
Submit
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