Covid Student Screening Form - Harris Institute

First Name: *

Last Name: *

Email: *

Date of birth: *//

Phone number: *

Are you experiencing any of the following symptoms:

Fever of 37.8C or higher *

Yes
No

Chills *

Yes
No

Cough or runny nose *

Yes
No

Difficulty breathing or Shortness of breath *

Yes
No

Malaise (severe fatigue or feeling generally unwell) *

Yes
No

In the last 14 days have you:

Been in close contact with someone who has a confirmed or probable case of Covid-19? *

Yes
No

Commitment to this plan

By 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 *//

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Harris Institute Student Screening

Are you experiencing any of the following symptoms:

In the last 14 days have you:

Commitment to this plan