COVID-19 Daily Screening Questionnaire Please enable JavaScript in your browser to complete this form.Name of dancer entering the building *FirstLastDate *1. Does your child attending today have any of the following symptoms:Fever: *YesNoCough: *YesNoShortness of breath or difficulty breathing: *YesNoSore throat: *YesNoRunny nose or congestion: *YesNoFeeling unwell: *YesNoNausea, vomiting or diarrhea: *YesNoMuscle aches: *YesNoHeadache: *YesNoNew loss of sense of taste or smell: *YesNoConjunctivitis: *YesNo2. Have you, or anyone in your household, traveled outside of Saskatchewan in the past 14 days?Required *Yes (please self-monitor for 14 days)No3. Have you, or anyone in your household, in the past 14 days travelled to a community in Saskatchewan with a COVID-19 outbreak?Required *YesNo4. Have you or anyone in your household been in direct UNPROTECTED contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?Required *YesNo5. Have you, or anyone else in your household traveled internationally and/or been instructed to self-isolate for any other reason?Required *YesNoNOTICEIf you answered "yes" to questions #1, #4 or #5, please DO NOT enter the studio at this time.If you have recently developed any of these symptoms, please call 811 or visit: https://www.saskatchewan.ca/government/health-care-administration-and-provider-resources/treatment-procedures-and-guidelines/emerging-public-health-issues/2019-novel-coronavirus/covid-19-self-assessment to do a self-assessment to see if you require testing.Be sure to practice good hand hygiene (use hand sanitizer or wash hands with soap and water for at least 20 seconds) before entering and leaving the building.Our goal is to minimize the risk of illness to you, your children and family and our staff. We thank you for your cooperation and understanding.6. SignatureRequired *I understand the questions asked and acknowledge the responses in the Daily Screening Questionnaire.NameSubmit
