COVID-19 Create Your Certificate Template

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COVID-19 Daily Self Declaration

John Doe

I attest the following:

  • I did not travel outside of Canada in the past 14 days

  • I did not tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE

I am well today and do NOT have any of the following symptoms:

  • Fever (higher than 37.5 C)

  • New onset of cough

  • Worsening chronic cough

  • Shortness of breath

  • Difficulty breathing

  • Sore throat

  • Difficulty swallowing

  • Decrease or loss of sense of taste or smell

  • Chills

  • Headaches

  • Unexplained fatigue/malaise/muscle aches (myalgias)

  • Nausea/vomiting, diarrhea, abdominal pain

  • Pink eye (conjunctivitis)

  • Runny nose or nasal congestion without other known cause

If I am 70 years of age or older, I am NOT experiencing any of the following symptoms:

  • Delirium

  • Unexplained or increased number of falls

  • Acute functional decline

  • Worsening of chronic conditions

Date: June 22, 2020

Published by Gutenberg Certs

COVID-19 Self Declaration Template