CTS COVID-19 Screening

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number* This field is required.

Area Code

Phone Number

4

What date is the program you are attending? (For overnight programs/multi-day programs, please put the start date)* This field is required.

Date

5

What program have you registered for?* This field is required.

6

Have you or anyone in your household shown any flu-like symptoms in the past 2 weeks? (see symptoms below)* This field is required.Fever or chills Cough Difficulty breathing Sore throat Loss of sense of smell or taste Headache Extreme fatigue or tiredness Diarrhea Loss of appetite Nausea or vomiting Body aches

YESNO

7

Have you or anyone in your household travelled outside of BC in the past 2 weeks?* This field is required.

YESNO

8

Did you have close contact with a person with confirmed COVID-19 within the last 14 days?* This field is required.A close contact is someone confirmed to have COVID-19 who you live with or otherwise had close face to face contact (within 2 metres) while they had symptoms or in the 48 hours before their symptoms started. Note: This means you would have been contacted by your health authority’s public health team.

YESNO

9

Can you provide your own transportation to and from the program? (We cannot provide group transportation at this time)* This field is required.

YESNO