COVID-19

Participation Consent Form

Name*

First Last

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand due to the frequency and proximity of interaction during this course and the characteristics of the novel coronavirus and the characteristics of this course I have an elevated risk of contracting the novel corona virus and still wish to participate.

I am fully vaccinated for Covid-19*

An individual is considered fully vaccinated if it has been more than 2 weeks since they received the last shot of a 2-dose vaccine (for example, Moderna or Pfizer) or a single dose vaccine (J&J).

Yes
No

I have a fever greater than 38°C / 100°F*

Yes
No

I have a new cough*

Yes
No

I have shortness of breath*

Yes
No

I have flu-like symptoms*

Yes
No

I have tested positive for the novel coronavirus*

Yes
No

I tested positive on this date*

I have since been confirmed negative*

Yes
No

I was confirmed negative on this date

I was confirmed negative by

Swab test
Blood test
Doctor

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I am currently waiting for the results of a laboratory test for the novel coronavirus.*

Yes
No

I have been outside the country in the past 14 days.*

Yes
No

Consent*

I understand it is recommended to maintain social distancing of at least 2 metres (6 feet) and that a mask must be worn all times when social distancing is not possible and in enclosed spaces.*

Consent*

I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by any governmental health agency.*

Signature*

Comments

This field is for validation purposes and should be left unchanged.