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Carriage House
Site Assessment Questionare

First Name

Last Name

Company

Email

Phone

Lot Number

1. Do you have any of the following symptoms or signs? Symptoms should not be Chronic or related to other known causes or conditions.

Fever or chills? *

YES*

No

Difficulty breathing/shortness of breath *

YES*

No

Cough? *

YES*

No

Sore throat, trouble swallowing *

YES*

No

Runny nose/stuffy nose or nasal congestion *

YES*

No

Decrease or loss of smell or taste *

YES*

No

Nausea, vomiting, diarrhea, abdominal pain *

YES*

No

Not feeling well, extreme tiredness, sore muscles *

YES*

No

2. Have you travelled outside of Canada in the past 14 days? *

YES*

No

3. Have you had close contact with a confirmed or probable case of COVID-19? *

YES*

No

4. Have you been vaccinated for COVID 19? *

Yes

No

I don't want to disclose

*If you answer yes to any of the following questions, please return home and follow Covid quarantine procedures.

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