Etz Chayim Coronavirus Self Declaration Form

Coronavirus Self Declaration Form

For the health and safety of our community, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
Name

First Name Last Name
Have you travelled outside of Manitoba in the last 14 days, excluding personal travel to border communities?

Yes No
Have you been in contact in the last 14 days with someone that is confirmed to have COVID-19?

Yes No
Have you been in a setting in the last 14 days that has been identified as a risk for acquiring COVID-19, such as on a flight, at a workplace or an event?

Yes No

Please state whether you've experienced/are experiencing the following

	Yes	No
Fever
Cough
Sore Throat/hoarse voice
Shortness of breath/breathing difficulties
Loss of Taste or smell
Vomiting or diarrhea for more than 24 hours

Do you have any of the following symptoms not related to asthma or allergies?

I acknowledge that the information I've given is accurate and complete.
Date

Month Day Year
Date
Signature

Clear
Email
example@example.com
For everyone's safety: As per Manitoba Government - stay home if you have any symptoms. Thank you for your cooperation.
Should be Empty: