SIGNATURE INDIAN CUISINE Toggle NavigationHomeTakeout MenuOrder OnlineDeliveryAbout UsContactCOVID-19 Screening HomeTakeout MenuOrder OnlineDeliveryAbout UsContactCOVID-19 Screening COVID-19 SCREENING QUESTIONAIRE First & Last NameDate*Have you travelled outside of Canada in the past 14 days?*If your answer is yes please self isolate for 14 days YesNoHave you had close contact with a confirmed or probable case of COVID-19?*If your answer is yes please self isolate and contact your health providerYesNoDo you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions. Fever or chills*YesNoDifficulty breathing or shortness of breath*YesNoCough*YesNoSore throat, trouble swallowing*YesNoRunny nose/stuffy nose or nasal congestion*YesNoDecrease or loss of smell or taste*YesNoNausea, vomiting, diarrhea, abdominal pain*YesNoNot feeling well, extreme tiredness, sore muscles*YesNoThis site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.SUBMITThank you! Your questionaire have sucessfully submited. Results of Screening Questions: • If the individual answers NO to all questions from 1 through 3, they have passed and can enter the workplace. • If the individual answers YES to any questions from 1 through 3, they have not passed and should be advised that they should not enter the workplace (including any outdoor, or partially outdoor, workplaces). They should go home to self-isolate immediately and contact their health care provider / PreviousNextPausePlayClose
