|
Does the person attending the activity, have any of the below symptoms (Q1 - Q14): |
YES / NO
|
Q1 |
Fever |
YESNO |
Q2 |
Cough |
YESNO |
Q3 |
Shortness of Breath/Difficulty Breathing |
YESNO |
Q4 |
Sore Throat |
YESNO |
Q5 |
Chills |
YESNO |
Q6 |
Painful Swallowing |
YESNO |
Q7 |
Runny Nose/Nasal Congestion |
YESNO |
Q8 |
Feeling Unwell/Fatigued |
YESNO |
Q9 |
Nausea/Vomiting/Diarrhea |
YESNO |
Q10 |
Unexplained loss of appetite |
YESNO |
Q11 |
Loss of sense of taste or smell |
YESNO |
Q12 |
Muscle/Joint Aches |
YESNO |
Q13 |
Headache |
YESNO |
Q14 |
Conjunctivitis |
YESNO |
Q15. |
Have you, or anyone in your household, travelled outside of Canada in the last 14 days? |
YESNO |
Q16. |
Have you or your children attending the program had close unprotected* contact (face-to-face contact within 2 metres/6 feet) with someone who is ill with cough and/or fever? |
YESNO |
Q17. |
Have you or anyone in your household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19? |
YESNO |
Q18. |
Have you had your school or AHS contact you to self isolate within a week? |
YESNO |