COVID-19 Screening - Township of Puslinch

Name *

First

Last

By-Law File or Building Permit # *

Phone *

Address *

Address Line 1

Address Line 2

City

Province

Postal Code

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have. *

In the last 14 days, have you travelled outside of Canada? *

No
Yes

In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19? *

No
Yes

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *

No
Yes

In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? *

No
Yes