5678 Dancer Screening Tool
To stop the spread of COVID19, dancers are required to use the self-screening tool below.  A copy of this questionnaire will be sent to COVID19@5678dancestudio.com for our records to aid contact tracing and in keeping with the COVID19 guidelines outlined by the Ministry of Health Ontario.  This questionnaire must be completed prior to a dancer’s entry into the dance studio.
 
The form is also available as a PDF for increased accessibility (https://covid-19.ontario.ca/covid19-cms-assets/2021-10/EN_Patron_Screening_v9%20Oct25%20Final.pdf).  Dancers choosing to submit their questionnaire this way should fill out their form, take a photo of it and email it to: COVID19@5678dancestudio.com prior to entering the facility.  Please note, the form must be completed every time a dancer enters the facility and must have unique dates and teacher fields.  Thank you for your cooperation.

This form complies with the COVID-19 Screening Tool for Businesses and Organizations (Screening Patrons)
Version 9 – October 25, 2021
In Google anmelden, um den Fortschritt zu speichern. Weitere Informationen
Dancer's name *
Responsible adult filling out form (if dancer is a child):
Date *
TT
.
MM
.
JJJJ
Which age category does the Dancer fit into? *
Teacher(s) of today’s dance class(es) *
Pflichtfrage
1. Do any of the following apply to you?  Please select the correct answer(s).  Personal health information is not collected when you complete this screening tool. The purpose of this question is to provide accurate isolation instructions which are based on vaccination status. *
Pflichtfrage
2. Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions.
The symptoms listed here are the symptoms most commonly associated with COVID-19. If you have these symptoms, you should isolate and seek testing.

Please note that rapid antigen testing is not to be used for those with symptoms of COVID-19 or for contacts of known COVID-19 cases.
Fever and/or chills [Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher] *
Cough or barking cough (croup) [Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have] *
Shortness of breath [Not related to asthma or other known causes or conditions you already have] *
Decrease or loss of smell or taste [Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have] *
For Adults (18 years or older): Fatigue. lethargy, malaise and/or muscle aches/joint pain [Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have); If you received a COVID-19 vaccination in the last 48 hours and are only experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”]
Auswahl löschen
For children/youth (17 years or younger): Nausea, vomiting and/or diarrhea [Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have]
Auswahl löschen
3. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)? *
4. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing. *
5. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19? If public health has advised you that you do not need to self-isolate, select “No.” *
6. In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? If you have since tested negative on a lab-based PCR test, select “No.” *
7. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?If you have since tested negative on a lab-based PCR test, select "No." *
8. In the last 14 days, has someone in your household (someone you live with) travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)? *
9. In the last 10 days, has someone in your household (someone you live with) been identified as a ”close contact” of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self-isolate? *
10. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? Children/Youth (17 years old or younger): fever and/or chills; cough or barking cough; shortness of breath; decrease or loss of taste or smell; nausea, vomiting and/or diarrhea Adults: (18 years old or older): fever and/or chills; cough or barking cough; shortness of breath; decrease or loss of taste or smell; tiredness; muscle aches. If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is only experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.” *
Weiter
Alle Eingaben löschen
Geben Sie niemals Passwörter über Google Formulare weiter.
Dieses Formular wurde bei 5678 Dance Studio erstellt. Missbrauch melden
Google Formulare