LAKESHORE SWIM CLUB COVID-19 SELF-SCREENING HEALTH QUESTIONNAIRE (rev. Sept 20 2021)

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This questionnaire MUST be completed before practice unless you have been informed that the practice facility will conduct the screening questionnaire.

Complete this form regardless of your vaccination status.

Email *

Swimmer's Name *

The following questions are to ascertained before any in-person training:

Group *

For practice day *

Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions. *

Fever or chills

Difficulty breathing or shortness of breath

Cough

Decrease or loss of smell or taste

Nausea, vomiting, diarrhea, abdominal pain

Headache that’s unusual or long lasting

Not feeling well, extreme tiredness, sore muscles

Required

Is someone in the household currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms, and a Public Health Unit (PHU) has told you to self-isolate? *

Yes

Are you waiting for direction from a PHU concerning a possible COVID-19 close contact exposure? *

Yes

Have you been deemed a close contact with someone who currently has COVID-19 and a PHU authority has told you to self-isolate? *

Yes

In the last 14 days, have you or someone in your household been in close physical contact with someone who currently has COVID-19? This includes getting a COVID Alert exposure notification. *

Yes

Are you a medical professional AND have you been in contact with or cared for someone with COVID-19 in the last 14 days without appropriate medical grade PPE? *

Yes

Have you or someone within your household travelled outside the country within the last 14 days and are required by the Canada Public Health Authority to quarantine/isolate? *

Yes

Next Steps

You must answer NO to all the above questions before attending an activity.

If you answer ‘YES’ to any of the above, you cannot participate in the activity and you must email covid@lakeshoreswimclub.com immediately. Follow the COVID safety protocols specified at LSC's COVID Safety Plan web page here: https://www.teamunify.com/team/canlsc/page/parent-info/covid-safety-plan

A copy of your responses will be emailed to the address you provided.

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