Daily Health Check Confirmation Form Date* Date Format: MM slash DD slash YYYY Location*School Name 1School Name 2School Name 3School Name 4School Name 5School Name 6School Name 7School Name 8School Name 9School Name 10School Name 11School Name 12School Name 13School Name 14School Name 15School Name 16School Name 17School Name 18School Name 19School Name 20School Name 21School Name 22School Name 23School Name 24School Name 25School Name 26School Name 27School Name 28School Name 29School Name 30School Name 31School Name 32Your Name* First Last Administrator/Manager Email* Environmental COVID-19 check*I confirm that I have not travelled outside of Canada in the past 14 days, been identified by Public Health as a close contact of someone with COVID-19 or been told to self-isolate by Public HealthOne or more of these situations apply to meDaily Health Check*Refer to the list of common COVID-19 symptomsI confirm that I do not have any new or worsening symptoms of COVID- 19I have one or more new or worsening symptoms of COVID-19