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COVID -19 Symptoms Checklist
For Gli Azzurri Dancers
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* Indicates required question
Email
*
Your email
Dancer Name
*
Your answer
Date of practice
*
MM
/
DD
/
YYYY
Do you have a fever ( greater than 38C)?
*
Yes
No
Have you experienced any Unexplained symptoms of coughing, sneezing?
*
Yes
NO
Do you have shortness of breath or difficulty breathing?
*
Yes
NO
Do you have UNEXPLAINED sore throat?
*
Yes
No
Do you have UNEXPLAINED runny nose?
yes
no
Clear selection
Has anyone in your household experiences any of the above symptoms in the last 14 days?
Yes
No
Clear selection
Have you or anyone in your household traveled outside of Canada in the last 14 days
Yes
NO
Clear selection
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
Clear selection
Did you answer yes to any of the COVID 19 symptoms checklist list questions?
Yes
No
Clear selection
If the DANCER has answered yes to any of this questions please do not attend the event and contact your instructor.
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