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Rollerplex Safe Entry Protocol
Please proceed to complete the required covid-19 screening
7
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1
Full name
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First Name
Last Name
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2
Phone Number
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3
1. Do you or anyone in your household have a fever?:
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Temperature of 37.8 degrees Celsius/ 100 degrees Fahrenheit or higher
Yes
No
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4
2. Do you have any of the following signs or symptoms?:
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COUGH OR BARKING COUGH (continuous, more than usual, making a whistling noise when breathing - not related to asthma, or known respirator condition you already have)
SHORTNESS OF BREATH (out of breath, unable to breathe deeply - unrelated to asthma or other known causes or conditions you already have)
MUSCLE ACHES/ JOIN PAINT (unusual, long-lasting, not related to getting a COVID-19 vaccine in the last 48 hours)
UNEXPLAINED FATIGUE OR MAILAISE (unusual, long-lasting, not related to getting a COVID-19 vaccine in the last 48 hours)
DECREASE/ LOSS OF TASTE OR SMELL (not related to season allergies, neurological disorders, or other known conditions you may have)
EXTREME TIREDNESS (unusual fatigue, lack of energy, not related to getting a COVID-19 vaccine in the last 48 hours, depression, insomnia, thyroid dysfunction or other known causes or conditions you already have)
NONE OF THE ABOVE
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5
3. Have you travelled or have had close contact with anyone who has travelled in the past 14 days AND have been told to quarantine?
*
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Yes
No
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6
4. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
*
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Yes
No
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7
5. Have you had close contact with anyone with a respiratory illness or a confirmed or probable/ suspected case of COVID-19?
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Yes
No
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