COVID-19 Screening Checklist

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This form is for participants in MAS Session 101-7E (August 3 to 7).

It is MANDATORY that this be filled out daily before joining the group.

Student's First Name *

Student's Last Name *

Does the person attending have any of the below symptoms: *

Yes

Fever

Cough

Shortness of breath / Difficulty breathing

Sore throat

Chills

Painful swallowing

Runny nose / Nasal congestion

Nausea / Vomiting / Diarrhea

Feeling unwell / Fatigued

Unexplained loss of appetite

Loss of sense of taste or smell

Muscle / Joint aches

Headache

Conjunctivitis (pink eye)

Have you, or anyone in your household, travelled outside of Canada in the last 14 days? *

Yes

Have you or your children attending the program had close unprotected* contact (face-to-face contact within 2 metres / 6 feet) with someone who is ill with cough and/or fever? *

* “unprotected” means close contact without appropriate personal protection equipment (PPE)

Yes

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? *

* “unprotected” means close contact without appropriate personal protection equipment (PPE)

Yes

If an individual answered yes to any of the questions above, they will not be allowed to participate in the camp.

I attest that the answers provided in this form are true. *

Name of parent or guardian who completed the form:

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