COVID-19

I am taking this screening as a: *

Student/Child
Employee
Visitor or Parent/Caregiver

You must choose one of the above.

First and Last Name *

*If a parent/Caregiver is entering... You must fill out another form with parent/Caregiver name as well

Phone Number *

This information is for Contact Tracing. Thank you!

Please record the Date of Class(es) *

This information is for Contact Tracing. Thank you!

Start Time - Finish Time *

This information is for Contact Tracing. Thank you!

Are you... Fully Vaccinated against COVID-19 And/Or aged 11 or younger? *

Yes
No

Do any of the following international travel scenarios apply to you? In the last 14 days: you travelled outside of Canada and were told to quarantine you travelled outside of Canada and told to not attend school/child care someone you live with returned from outside Canada and is isolating while waiting for COVID-19 test results *

Yes
No

If a child/student is not fully vaccinated but is exempt from federal quarantine because they travelled with a fully vaccinated companion, they must not go to school/child care for 14 days. Select “Yes” if this applies.

In the last 5 days, have you experienced any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have. Select “None of the above” if symptoms have been improving for 24 hours and you tested negative for COVID-19 on a single PCR test or two rapid antigen tests taken 24 to 48 hours apart.

Anyone who is sick or has any symptoms of illness, including those not listed below, should stay home until their symptoms are improving for 24 hours and seek assessment from their health care provider if needed.

Fever and/or chillsTemperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Yes

Cough or barking cough (croup)Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)

Yes

Shortness of breathOut of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)

Yes

Decrease or loss of taste or smellNot related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

Yes

Muscle aches/joint painUnusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)

Yes

Extreme tirednessUnusual fatigue, lack of energy (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

Yes

Sore throatPainful or difficulty swallowing (not related to post-nasal drip, acid reflux, or other known causes or conditions you already have)

Yes

Runny or stuffy/congested noseNot related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have

Yes

HeadacheNew, unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, tension-type headaches, chronic migraines, or other known causes or conditions you already have)

Yes

Nausea, vomiting, and/or diarrhea Not related to irritable bowel syndrome, anxiety, menstrual cramps, medication side effects, or other known causes or conditions you already have

Yes

If you answered "NO" To all the above... Check below...

None Of The Above

In the last 5 days, have you tested positive for COVID-19? This includes a positive COVID-19 test result on a lab-based PCR test, rapid antigen test, or home-based self-testing kit. *

Yes
No

Do any of the following apply? You live with someone who is currently isolating because of a positive COVID-19 test You live with someone who is currently isolating because of COVID-19 symptoms You live with someone who is waiting for COVID-19 test results *

Yes
No

Select “No” if the person has not tested positive for COVID-19 and only has one of these symptoms: sore throat or difficulty swallowing, runny or stuffy/congested nose, headache, extreme tiredness, muscle aches or joint pain, nausea, vomiting and/or diarrhea.

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. *

Yes
No

If you already went for a test and got a negative result, select "No."

Have you been identified as a “close contact” of someone who currently has COVID-19 and been advised to self-isolate? *

Yes
No

If public health guidance provided to you has advised you that you do not need to self-isolate, select “No.”

I consent for my child to be spotted and/or receive tactile corrections from their teachers. Proper mask-wearing and sanitizing will be followed. *

Yes
No

I consent to Pure Energy Performance Inc. releasing this information to Public Health in the event it is needed to assist with contact tracing. *

Parent/Caregiver Name *Dancers Name if over 18 Years of age.

Please complete the following questions before beginning your class today.

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