COVID-19 Questionnaire

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Name*

First

Last

Phone*

Email*

Has anyone in your household or office been diagnosed with COVID-19 in the past 7 days?*

Yes

No

Is anyone in your household or office self-isolating, for example, because they have travelled recently or recently been tested for COVID19?*

No

Yes

Is anyone in your household or office unwell with symptoms related to COVID-19? This includes fever, coughing, sore throat or sneezing.*

No

Yes

What's your current COVID-19 vaccination status?*

Not vaccinated

Vaccinated

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