ABRA Health Assessment

ABRA Covid-19 Health Assessment:
Date *

Year Month Day

AM/PM Option
Last Name *
Address *

Street Address
Phone Number *
E-mail
example@example.com
Have you or anyone in your household travelled outside of Canada in the past 14 days? *

Yes No
Have you or anyone in your household tested positive for Covid-19 in the past 14 days? *

Yes No
Are any members of your household currently experiencing any of the following symptoms: fever above 38 degrees Celsius, cough, shortness of breath/difficulty breathing, sore throat, runny nose? *

Yes No
Do you understand and consent to the terms outlined in the COVID-19 lake use information sheet (https://bit.ly/2XZiIwO)? *

I agree I disagree
Guest names (If applicable) leave blank if bringing no guests*
INCLUDE FULL NAMES
Guest community
Which community are your guest(s) from?
*Maximum of 2 guests per household. Children who are mobile (i.e., crawling) count as guests.
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ABRA Covid-19 Health Assessment: