*Restaurant* Contact Tracing Form
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Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you visited or returned from another country within the last Thirty (30) days?
Yes
No
Please state the location.
What were your travel dates?
-
Month
-
Day
Year
Date
Have you visited or returned from another domestic location within the last 14 days?
Yes
No
Please state the location.
What were your travel dates?
-
Month
-
Day
Year
Date
Have you had any contact with a suspected or confirmed case of COVID- 19 (ex. living/working/travelling together) or visited a healthcare facility used for COVID-19 quarantine purposes within the last 14 days?
Yes
No
Please check if you have experienced any of the following within the last 14 days:
Fever
Difficulty in breathing
Colds
Body Measles
Cough
Fatigue
Sore Throat
Headache
None
Other
Are you a senior citizen or below 21 years old?
Yes
No
For Senior Citizens and those below 21 years old, (or those with immunodeficiency, comorbidities or other health risks, and pregnant women): I am aware of the risks and I understand the possible health consequences of visiting public places during GCQ/MGCQ. I am fully accountable for my health given my circumstances.
Agree
Disagree
Submit
Should be Empty: