MMS Big White

Hut COVID Form

Todays Date

First Name

Last Name

Email Address

Are you experiencing any of the following: new or worsening cough, shortness of breath, sore throat, runny nose, sneezing, nasal congestion, hoarse voice, difficulty swallowing, new smell or taste disorder, nausea, vomiting, diarrhea, abdominal pain, unexplained fatigue, malaise, chills, headache?

Yes

Have you traveled outside of Canada in the past 14 days?

Yes

Have you had close contact with anyone who has traveled outside of Canada in the past 14 days?

Yes

Do you have a fever?

Yes

Have you had close contact with anyone with a respiratory illness or a confirmed or probable case of COVID-19?

Yes

By checking this box, the person named in this survey has agreed that they will clean and disinfect any and all surfaces or items they touch before and after use in the hut such as dishes, countertops, remote controls, etc

I Agree