NFDC Self-Screening Questionnaire

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ALL visitors, parents, dancers and staff are required to complete the following form prior to entering the JP2 school.

This tool has been developed to support activity organizers and facility operators in reducing the risk of transmission of COVID-19 among attendees. The tool is meant to be used to assist with assessing attendees who may be symptomatic, or who may have been exposed to someone who is ill or has confirmed COVID-19.

Attendees should fill out this checklist prior to arriving at NFDC. If an individual answers YES to any of the questions, they are not be allowed to enter the building. Please self-isolate and call 811 for assistance.

Please submit a form each day you enter the facility.

*Must fill out a separate form for each guest* **This Questionnaire must be completed DAILY before entering**

First Name *

Last Name *

Email *

Cell Phone Number *

Do you / your child have any new onset (or worsening) of any of the following symptoms: *

YES

Fever

Cough

Shortness of Breath / Difficulty Breathing

Sore throat

Chills

Painful swallowing

Runny Nose / Nasal Congestion

Feeling Unwell / Fatigued

Nausea / Vomiting / Diarrhea

Unexplained loss of appetite

Loss of taste or smell

Muscle / Joint aches

Headache

Conjunctivitis (commonly known as pink eye)

Has the attendee traveled out of Canada in the last 14 days? *

YES

Has the attendee had close contact* with a confirmed case of COVID-19 in the last 14 days? *

YES

Has the attendee had close contact with someone displaying symptoms of COVID-19 in the last 14 days? *

YES

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