E-mail: * Date of Attendance: * Full Name: * Phone Number: * Numbers of People from Same Family: * —Please choose an option—12345 Street Address: * City: * Postal Code: * Car Registration Plate: * Essential Visitors Essential visitors include a person: performing essential support services (e.g., food delivery, phlebotomy, maintenance, family providing care and other health care services required to maintain good health); OR visiting a very ill or palliative resident. Screening Questions Do you have any of the following new or worsening symptoms or signs? Shortness of breath: * YesNo Runny nose, sneezing or nasal congestion(in absence of underlying reasons for symptoms such as seasonal allergies and post nasal drip): * YesNo Difficulty swallowing: * YesNo Nausea/vomiting, diarrhea, abdominal pain: * YesNo 1. Chills & Headaches: * YesNo 3. Do you have a fever?: * YesNo New or worsening cough: * YesNo Sore throat: * YesNo Hoarse voice: * YesNo New smell or taste disorder(s): * YesNo Unexplained fatigue/malaise: * YesNo 2. Have you travelled outside of Canada or had close contact with anyone that has travelled outside of Canada in the past 14 days?: * YesNo 4. Have you had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19?: * YesNo I/We, understand that the novel coronavirus causes the disease known as COVID-19. I/We understand the novel coronavirus has a long incubation period during which the carriers of the virus may not show not show the symptoms and may still be contagious. I/We understand that : Physical distancing of 2.0 meters may not be possible. I/We must sanities My/Our hands before entering the Vraj Campus. I/We must make all attempts to cover my mouth and nose in the event of coughing and/or sneezing and then immediately sterile my/our hands. I/We will minimize the touching of common surface/areas. I/We may be unable to proceed with services at Vraj Campus if they are deemed unsafe to Myself/Our Selves. I/We may NOT bring children or anyone else who has low Immunity. I/We understand the people at Vraj Canada Campus will do everything possible to minimize the spread of COVID-19, but will not hold them responsible should I/We contract COVID-19. I/We confirm that: I/We am/are not currently positive for COVID-19. I/We am/are not waiting for the results of a laboratory test for COVID-19. I/We have not returned to Canada, whether by car, air, sea, bus or train in the past 14 days. I/We have not been identified as a contact of someone who has test positive for COVID-19 or been asked to self-isolate by any government agency. I/We am/are not in high risk category for increased illness or death from COVID-19, including : diabetes, cardiovascular disease, hypertension, lung disease including moderate to severe asthma, being immunocompromised (including transplant recipient), having active malignancy or over the age of 65.I am NOT presenting with any of the following symptoms of COVID-19:- Fever > 38C, or 100F, chills or body aches- Cough- Sore Throat- Shortness of breath / Difficulty breathing- Flu-like symptoms- Runny Nose- Loss of smell or taste I/We will immediately notify the Vraj Canada if I/We contract the virus within two weeks following my visit. By signing below, I/We verify that the information I/We have provided on this form is truthful and accurate. * I agree to the above Conditions.