JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Adult Lessons - St. Albert Nordic COVID-19 Checklist
If you answer yes to any of the following statements, please stay home and use the AHS Online Assessment Tool to determine if testing is recommended.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
This form must be completed by the participant or their legal guardian prior to attending each lesson.
Participant Name
*
Your answer
Does the person attending the activity have any of the following symptoms
Fever
Cough - new or changed
Shortness of Breath/ Difficulty Breathing – new or changed
Sore throat
Chills
Painful swallowing
Runny nose / Nasal congestion - new or changed
Feeling unwell/ Fatigued
Nausea/ Vomiting/ Diarrhea
Unexplained loss of appetite
Loss of sense of taste or smell
Muscle/ Joint aches – unexplained and unrelated to physical activity
Headache
Conjunctivitis
Have you, or anyone in your household, travelled outside of Canada in the last 14 days? If so and the individual travelled for work and is not displaying symptoms, you may select no.
*
Yes
No
Required
Have you or your children attending the program had close unprotected contact (face-to-face contact within 2 meters/ 6 feet) with someone who is ill with cough and/or fever?
Yes
No
Have you or anyone in your household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?
*
Yes
No
Required
If you answer yes to any of the above, please stay home and use the AHS Online Assessment Tool to determine if testing is recommended.
A copy of your responses will be emailed to the address you provided.
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
