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MVDA COVID-19 Screening Questionnaire
Please complete this prior to In Person dance class each day.
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* Indicates required question
Student's Name:
*
Your answer
Do you have any of the below symptoms?
*
Choose
Fever (greater than 38.0 Degrees C)
Cough
Shortness of Breath / Difficulty Breathing
Sore Throat
Runny Nose
None
Have you, or anyone in your household travelled outside of Canada in the last 14 days?
*
Yes
No
Required
Have you, or anyone in your household been in contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?
*
Yes
No
Required
Are you currently being investigated as a suspect case of COVID-19?
*
Yes
No
Required
Have you tested positive for COVID-19 within the last 10 days?
*
Yes
No
Required
Parent/ Guardian Name:
*
Your answer
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