Covid-19 | Level Up Cambridge

STAFF/ ATHLETES - COVID-19 SELF-SCREENING ATTESTATION

NOTE: 1. Anyone entering Level Up Cambridge building must conduct a self-assessment DAILY to confirm that they do not have any of the symptoms or meet any of the conditions listed below. All visitors and staff must provide confirmation that they have completed this self-assessment. 2. If you cannot confirm ALL of the statements below, please do not enter Level Up Cambridge.

First Name

Last Name

I do NOT exhibit any of the symptoms listed below: - Fever and/or chills - Cough or barking cough (croup) - Shortness of breath - Decrease or loss of taste or smell - Sore throat or difficulty swallowing - Runny or stuffy/congested nose - Headache - Nausea, vomiting a- Extreme tiredness or muscle ache.nd/or diarrhea -

I have NOT travelled outside of Canada in the last 14 days.

I have NOT been identified as a 'close contact' of someone who currently has COVID-19 within the past 14 days.

I have NOT been told to self-isolate (stay at home) by a doctor, health care provider, or public health unit.

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!