Student Daily Screening Form

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DANCERS MUST FILL OUT THIS QUESTIONNAIRE EACH DAY BEFORE COMING TO CLASS.

If an individual answers yes ✅ to any of the questions below, they cannot attend or participate in class. *Individuals with a fever, cough, shortness of breath, runny nose, or sore throat are required to isolate for 10 days OR receive a negative COVID-19 test and have no symptoms before returning to dance.

Dancers First Name *

Dancers Last Name *

Do you have any of the below symptoms: *

Please check box if you have any of the below symptoms. If you marked ✅ to any of the symptoms, the student SHOULD NOT attend dance today.

Fever (greater than 38.0C)

Cough

Shortness of Breath / Difficulty Breathing

Sore Throat

Running Nose / Nasal Congestion

None of the above

Required

Has you travelled outside of Canada in the last 14 days? *

Yes

Are you currently being investigated as a suspected case of COVID-19? *

Yes

Have you had close contact* with a confirmed case of COVID-19 in the last 14 days? *

Yes

Have you had close contact with a symptomatic** close contact of a confirmed case of COVID-19 in the last 14 days? *

** ‘Ill/symptomatic’ means someone with COVID-19 symptoms on the list above

Yes

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