Visitor Covid-19 Screening Form

Date

MonthDayYear
Date
Name

First NameLast Name
By signing below, I acknowledge that I have clicked on the link provided above to the Ontario Covid-19 Assessment WITHIN THE PAST HOUR and have answered all of its questions accurately and honestly and then relayed this information onto this form as per the following question.
The answer generated from the Ontario COVID-19 Assessment I took indicated that:
SIGNATURE OF TEMP
VISITOR'S STATUS
Should be Empty: