COVID-19 Screening Form

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This form is required to be completed by EACH parents/guardians/guests attending the Ring Night at BCIT-Westampton.

Guest's FIRST NAME *

Guest's LAST NAME *

BCIT STUDENT'S NAME *

Any of the symptoms below could indicate a COVID-19 infection and may put you at risk for spreading illness to others. Please note that this list does not include all possible symptoms with COVID-19. You may experience any, all or none of these symptoms. Please check daily for any of these symptoms:

SECTION A- IF TWO or MORE of the fields in this section are checked off, please do NOT attend this event. Leave blank if you have no symptoms.

Fever (measured or subjective)

Chills

Rigors (shivers)

Myalgia (muscle aches)

Headache

Sore Throat

Nausea or Vomiting

Diarrhea

Fatigue

Congestion or Runny Nose

SECTION B- IF AT LEAST ONE field in this section is checked off, please do NOT attend this event. Leave blank if you have no symptoms.

Cough

Shortness of Breath

Difficulty Breathing

New Loss of Smell

New Loss of Taste

IF ANY of the fields in the Close Contact / Potential Exposure section (below) are checked off, please do NOT attend this event.

Please verify if (Only check if applicable; otherwise leave blank):

You have had close contact (within 6 feet of an infected person for 15 or more minutes during a 24-hour period) with a person with COVID-19.

Someone in your household is diagnosed with COVID-19 or being tested for COVID-19.

You have traveled to an area of high community transmission.

Clear selection

By checking this box, I attest that I have no symptoms in either Column A or Column B and have not had any close contact or potential exposure. *

Confirmed

Required

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