Staff

Name *

First Name

Last Name

I do NOT have any of the following Covid-19 SYMPTOMS: fever, new onset of cough or worsening chronic cough, new or worsening shortness of breath or difficulty breathing, sore throat, runny nose, other. *

AGREE

DISAGREE

I do NOT have a HOUSEHOLD CONTACT who has tested positive for COVID-19 in the past 14 days. *

AGREE

DISAGREE

I have not TRAVELED outside the country in the past 14 days, or meet the Federal and Provincial requirements to be quarantine exempt upon my return. *

AGREE

DISAGREE

I declare that the information on this form is correct, and that it is my responsibility to notify the MSL Office at info@mslprojects.com if any information changes. For more information on symptoms, the definition of close contact, or travel restrictions, please visit www.albertahealthservices.ca/covid-19 *

AGREE