Self Assessment for Covid-19

This form needs to be filled out before you come to Jyoti Dham. Every attendee must fill out the form themselves.

Email

1

My vaccination status is:

I have received 0 doses

I have received 1 dose

I have received 2 doses

I have received 3 doses

2

I have tested positive for COVID-19 in the last 28 days

Yes

No

3

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

Yes

No

4

Are you currently experiencing any of these issues? Severe difficulty breathing, Severe chest pain, Feeling confused or unsure of where you are or Losing consciousness

Yes

No

5

In the last 10 days, have you been in “close contact” of someone who currently has COVID-19 OR received a COVID Alert exposure notification on your cell phone?

Yes

No