18+ DAILY SCREENING (Spectator, birthday party attendees, board members for meetings OR drop-in attendee)
If you have traveled outside Canada in the last 14 days, follow the Government of Canada Travel, Testing,
Quarantine and Borders instructions.

If an individual answers YES to any of the questions, they are not allowed to attend or participate in any
activity or program.

*This form will be updated to reflect any Government of Alberta and Alberta Health Services changes to questions and requirements.
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Email *
Today's Date: *
MM
/
DD
/
YYYY
Acitvity Start Time: *
Time
:
Participant First Name: *
Participant Last Name: *
Activity: *
Do you have any new onset (or worsening) of any of the following symptoms: *
Yes
No
Fever* (greater than 38℃)
Cough*
Shortness of breath/difficulty breathing*
Runny nose*
Sore throat*
Chills
Painful swallowing
Nasal congestion
Felling unwell/fatigued
Nausea/vomiting/diarrhea
Unexplained loss of appetite
Lose of sense of taste or smell
Muscle/joint aches
Headache
Conjunctivitis (pink eye)
If you answered “YES” to any symptom in question 1, stay home and do not attend or participate in the activity or program. Use the AHS Online Assessment Tool or call Health Link 811 to arrange for testing and to receive additional information on isolation. Individuals with fever, cough, shortness of breath, runny nose, or sore throat, are required to isolate for 10 days as per CHMOH Order 39-2021 OR receive a negative COVID-19 test and feel better before returning to activities, as long as they have no known exposure. If you answered “NO” to all questions you may attend the activity or program
By submitting this document electronically, I hereby certify all of the following information to be true. *
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