MLA Student - COVID 19 Daily Checklist

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COVID-19 Alberta Health Daily Checklist

Students must fill in this checklist each day prior to attending their classes at the school.
Please read carefully and follow the instructions.

Email addresses are collected for the purpose of notifying the respondent of possible COVID-19 exposure and are deleted after 14 days.

Email *

Full Name *

1. Have you been a household contact of a case of COVID-19 in the last 14 days? *

Yes and I am not double vaccinated. PLEASE STAY HOME FOR 14 DAYS FROM THE LAST DAY OF EXPOSURE AND MONITOR YOUR SYMPTOMS.

Yes and I am double vaccinated. Please monitor your symptoms and isolate immediately if they develop.

No - I am not experiencing any of these symptoms

Required

2. Have you tested positive for COVID-19? *

Yes and I am not double vaccinated. YOU MUST ISOLATE FOR 10 DAYS FROM THE ONSET OF SYMPTOMS OR UNTLY THEY RESOLVE, WHICHEVER IS LONGER.

Yes and I am double vaccinated. You must isolate for 5 days from the onset of symptoms or until they resolve, whichever is longer. You must wear a mask for up to 5 days after your isolation period if you are outside of your home.

No.

3. Do you have any new onset (or worsening) of the following symptoms: fever, cough, shortness of breath/difficulty breathing, sore throat, runny nose/nasal congestion, loss of sense of taste or smell? *

Yes and I am not double vaccinated. YOU ARE REQUIRED TO ISOLATE FOR 10 DAYS OR UNTIL YOUR SYMPTOMS RESOLVE, WHICHEVER IS LONGER.

Yes and I am double vaccinated. You are required to isolate for 5 days or until symptoms resolve, whichever is longer, plus 5 days of wearing a mask at all times when around others outside of home.

4. Do you have any new onset (or worsening) of the following symptoms: chills, painful swallowing, runny nose/nasal congestion, feeling unwell/fatigued, nausea/vomiting/diarrhea, unexplained loss of appetite, muscle/joint aches, headache, or conjunctivitis (commonly known as pink eye). *

Yes and I am not double vaccinated. YOU MUST ISOLATE FOR 10 DAYS FROM THE ONSET OF SYMPTOMS OR UNTLY THEY RESOLVE, WHICHEVER IS LONGER.

No. If you do not have any symptoms you may attend school.

5. I understand and agree that I am coming to attend my courses at Maple Leaf Academy at my own risk, Maple Leaf Academy has followed Alberta Health guidelines and has made every endeavour to protect its staff and students from COVID-19, will notify the school immediately if I have been exposed to COVID-19, Maple Leaf Academy is not liable if I get COVID-19. *

I understand and agree

I do not agree

Required

Send me a copy of my responses.

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