COVID-19 Self Screening Questionnaire

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For everyone's safety, we are conducting active screening for potential risks of transmitting COVID-19 with everyone entering our dojang. This screening questionnaire apply to all attendance and members, parent or guardians are responsible to provide any update.

Name of Student 1 *

Name of Student 2

Name of Student 3

Name of Parent/Guardian if 18 and under

1. Do you/your children have any of the following symptons: *

Fever

New or existing cough

Difficulty breathing

Sore throat

Chills

Painful swallowing

Runny nose/Nasal congestion

Feeling unwell/Fatigued

Nausea/Vomiting/Diarrhea

Unexplained loss of appetite

Loss of sense of taste or smell

Muscle/Joint aches

Headache

Conjunctivitis

Not applicable

2. Have you or anyone in your household travelled outside of Canada including the United States of America) within the last 14 days? *

3. Have your or your children had close contact with a person who has tested positive for COVID-19 or is suspected to have COVID-19? *

4. Have you or your children had close contact with a person who has a fever, cough or shortness of breath that started within 14 days of travel outside of Canada? *

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