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COVD-19 Health Questionnaire ➝
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Faculty
Audition
Artists
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Contact
2021 COVID-19 Screening Form
COVID-19 Health Screening
My Information:
First Name
Last Name
Email
Phone Number
Prior to the start of class, I confirm that:
Fever
I am not experiencing fever and/or chills (temperature of 37.8 degrees Celsius/100 degrees Farenheit or higher)
Cough
I am not experiencing a cough or barking cough (continuous/more than usual), or making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causes or conditions I already have)
Breathing
I am not experiencing shortness or breath, feeling out of breath, an inability to breathe deeply (not related to asthma or other known causes or conditions I already have)
Smell
I am not experiencing a decrease or loss of taste or smell (not related to seasonal allergies, neurological disorders or other known causes or conditions I already have)
Swallowing
I am not experiencing a sore throat, difficulty swallowing, or painful swallowing (not related to seasonal allergies, acid reflux or other known causes or conditions I already have)
Congestion
I am not experiencing a runny or stuffy/congested nose (not related to seasonal allergies, being outside in cold weather or other known causes or conditions I already have)
Headaches
I am not experiencing unusual, long-lasting headaches (not related to tension-type headaches, chronic migraines or other known causes or conditions I already have)
Nausea
I am not experiencing nausea, vomiting and/or diarrhea (not related to irritable bowel syndrome, anxiety, menstrual cramps or other known causes or conditions I already have)
Tiredness
I am not experiencing extreme tiredness or muscle aches, unusual, fatigue, lack of energy, or poor feeding in infants (not related to depression, insomnia, thyroid disfunction, sudden injury or other known causes or conditions I already have)
Travel
I have not travelled outside of Canada in the last 14 days
Close Contact
I have not been identified as a “close contact” of someone who currently has COVID-19 in the last 14 days
No Isolation
I have not been told by a doctor, health care provider or public health unit that I should currently be isolating (staying at home)
Household Travel
Nobody in my household has travelled outside of Canada in the last 14 days and is currently living within the home (i.e. are not isolating at a government-funded isolation centre)
Household Contact
Nobody in my household has been identified as a “close contact” of someone who currently has COVID-19
Household Symptoms
Nobody in my household is sick with the COVID-19 symptoms outlined above (new or worsening) and does not yet have a negative COVID-19 test result or alternative diagnosis from a health-care provider
Digital Signature
Digital Signature
Confirm Digital Signature
By adding your signature twice below, you confirm that the information above is accurate
Signed On
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