How old are you?
Below 18
Between 18 and 40
Between 40 and 65
Above 65
In the last 10 days, have you been tested for COVID‑19?
I was tested and my result was positive for COVID-19
I was tested and my result was negative for COVID-19
I was tested but I have not yet recieved my test results
I have not been tested in the last 10 days
Have you recently started experiencing any of these symptoms?
Fever or chills
Mild or moderate difficulty breathing
Sore throat
Sudden loss of taste or smell
None of the above
In the last 14 days, did any of these apply to you?
I lived with someone who has COVID-19
I cared for someone who has COVID-19
I might have been exposed to COVID-19
I've had no known exposure to COVID-19
Do you live in a long-term care facility?
I live in a long-term care facility
I don't live in a long-term care facility
In the last 14 days, did you work or volunteer in a healthcare facility?
I worked or volunteered in a healthcare facility
I did not worked or volunteered in a healthcare facility
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