Spreading the Music Corona Virus Screening Questionnaire

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Please complete this form for yourself and for any student you are responsible for.

This form is to provide additional safety information and contact tracing during the COVID-19 Pandemic. Please note, it is required to wear a face-mask at all times, wash your hands immediately upon entering the building, no excessive touching and practice good hygiene. We will not, in any circumstances, share your personal information with other individuals or organizations without your permission, including public organizations, corporations or individuals, except when applicable by law.

Your Full Name *

Email *

Who are you filling this out for? *

Myself

Student who attends Spreading the Music

Students Full Name

Have you or the student listed tested positive for COVID-19 within the last 14 days? *

No, I have not tested positive

Yes, though I have effectively quarantined and have recently retested negative.

Most recent negative COVID test date *

Date December 27, 2021 or sooner preferred

YYYY

Are you or the student listed above vaccinated for Covid-19? *

Yes, received my 1st dose of Pfizer or Moderna

Yes, fully vaccinated Pfizer, Moderna or J &J

Yes, fully vaccinated + booster

No, not vaccinated

Prefer not to say

How often do you get tested for COVID-19 be it for work, school or otherwise?

Frequently. Once a week to multiple times a week.

Often. Once a month to a couple times a month.

Sometimes. Only when symptoms arise or when I travel.

Rarely. I’ve never been tested.

Prefer not to say.

Clear selection

Are you or the student listed above over the age of 65?

Yes

Prefer not to say.

Clear selection

Signature of Parent or Student

Students who are well but who have a sick family member at home with COVID-19 should consider postponing your lesson. Positive responses to any of these would likely indicate a deeper discussion with your teacher before deciding to proceed. By having this lesson I understand there is a heightened risk of contracting or transmitting the Corona Virus or variants and can opt for online lesson at anytime. By signing this form, I have taken the required safety precautions before entering Spreading the Music, I feel safe and am ready to have music lessons in person, teach a lesson or comfortably use rehearsal space.

Signature *

Todays Date *

YYYY

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