Clarenville Nordic Covid 19 Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

To prevent the spread of the COVID-19 in our community and reduce the risk of exposure for our members, staff and guests, people (including all staff and instructors) attending our facility / activity are required to complete this brief screening questionnaire for each day that they attend a facility or activity.

Parents or guardians should complete the form for minor children.

Completed forms will be retained by our club for a period of one month to aid in contract tracing if necessary.

If the answer is “Yes” to any of the questions below, please DO NOT enter the facility or engage in the activity at this time. You should stay home and use the COVID-19 Self-Assessment Tool found on the government of Newfoundland and Labrador website.

If the answers are “No” to all of the questions below, you may attend our facility or engage in the activity.

TODAY'S DATE *

YYYY

Name *

Contact Number *

Do you have a fever and/or cough (new or worsening)? *

0 points

Yes

Do you have two or more of the following symptoms: *

0 points

Yes

Have you been in close contact with a known or suspected case of Covid-19 in the last 14 days? *

0 points

Yes

Have you traveled in the last 14 days outside the Atlantic Provinces or outside the communities along the Labrador - Quebec Border (Labrador City, Wabush, Fermont, the Labrador Straits area and Blanc Sablon? *

0 points

Yes

Have you been in close contact with anyone who has traveled outside the Atlantic Provinces in the past 14 days who has developed Covid-19 symptoms? *

0 points

Yes

If you are completing this questionnaire for other family members Please list their names below

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Clarenville Nordic. Report Abuse

Forms