Summer 2021 Daily Active Surveillance

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Please complete this form each day before coming to the studio. We are required by the Ministry of Health to keep these daily records.

Today's Date *

YYYY

Your First and Last Name (guardian) *

What is the first and last name of your child attending Collingwood School of Dance today? *

In the last 14 days, have they travelled outside of Canada? *

Yes

Has a doctor, health care provider, or public health unit told them that they should currently be isolating (staying at home)? *

This can be because of an outbreak, contact tracing, or after testing positive on a rapid antigen test.

Yes

In the last 14 days, have they been identified as a “close contact” of someone who currently has COVID-19? *

Yes

Are they currently experiencing any of these symptoms? *

Fever (>37.8 C/100.04 F), Chills, cough that's new or worsening, barking cough (making squeaky or whistling noise when breathing) (croup), shortness of breath (out of breath, unable to breathe deeply), sore throat, difficulty swallowing, runny, stuffy or congested nose not related to allergies, decrease or loss of taste or smell, headache, nausea, vomiting, diarrhea, extreme tiredness or muscle aches

Yes

None of the above

Is anyone they live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *

Yes

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