Harris Institute Student Screening After submission, you will receive a copy of your completed form to the email address provided below. Please enable JavaScript in your browser to complete this form.First Name: *Last Name: *Email: *Date of birth: *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone number: *Are you experiencing any of the following symptoms:Fever of 37.8C or higher *YesNoChills *YesNoCough or runny nose *YesNoDifficulty breathing or Shortness of breath *YesNoMalaise (severe fatigue or feeling generally unwell) *YesNoIn the last 14 days have you:Been in close contact with someone who has a confirmed or probable case of Covid-19? *YesNoCommitment to this planBy signing this form, I certify that I understand the importance of the quarantine procedure upon arrival in Canada, and will follow all criteria provided in this document, as well as all requirements provided by the Government of Canada, for a full 14 days.Candidate eSignature *(type your name)Date of eSignature *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Privacy PolicySubmit