COVID-19 self-assessment questionnaire

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​​For all parties appearing at the IRB: You must complete the following self-assessment questionnaire:

  • When you receive the Notice to Appear; and
  • if you or anyone you live with displays any of the symptoms at question 1 during the time you received the Notice to Appear and the day of the hearing.
  1. Have you or anyone you live with experienced any of the following symptoms in the last 14 days?
  2. New or worsening cough

    Yes No

    Shortness of breath

    Yes No

    Sore throat

    Yes No

    Runny nose, sneezing or nasal congestion (in absence of underlying reasons
    for symptoms such as seasonal allergies and post nasal drip)

    Yes No

    Hoarse voice

    Yes No

    Difficulty swallowing

    Yes No

    New smell or taste disorder(s)

    Yes No

    Nausea/vomiting, diarrhea, abdominal pain

    Yes No

    Unexplained fatigue/malaise

    Yes No

    Chills

    Yes No

    Headache

    Yes No

​​
  1. Have you travelled abroad or had close contact with anyone who has travelled in the past 14 days?
  2. Yes No

  3. Do you have a fever?
  4. Yes No

  5. Have you had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19 in the past 14 days?
  6. Yes, go to question 5 No

  7. Did you wear the required and/or recommended personal protective equipment according to the type of duties you were performing (e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures (AGMPs)) when you had close contact with a suspected or confirmed case of COVID-19?
  8. Yes No

If you answered “Yes” to any questions from 1 to 3, DO NOT go to IRB. Contact the Division immediately. The Division will reschedule the hearing.

If you answered “Yes” to question 4 and “No” to question 5, DO NOT go to IRB. Contact the Division immediately. The Division will reschedule the hearing.