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COVID-19 SCREENING FOR CPS PROGRAM
Please fill out the following health declaration form in order to participate in our activity. Submissions are only valid the day of your visit.
First Name
Last Name
Email
Are you/the person attending the CPS program presenting with a Fever?
No
Yes
Are you/the person attending the CPS Program experiencing a new or worsening cough?
No
Yes
Have you/the person attending the CPS Program have close contact with acute respiratory illness?
No
Yes
Do you/the person attending the CPS program have a confirmed case of Covid-19, or had close contact with a confirmed case of Covid-19?
No
Yes
Date
Initials
I confirm that the information given in this form is true
Submit
Thanks for submitting!
