COVID Screening

Please complete this questionnaire 1 day or less before attending class every week

To help us with your assessment and as a precaution to limit the risk of transmitting the COVID-19 virus, it is important we take measures to protect our students and staff.

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Full Name

Phone Number

Are you experiencing symptoms of a cough, fever, or having difficulty breathing?

Are you experiencing chills, fatigue, headache, sore throat, runny nose, stuffy or congested nose, lost sense of taste or smell, hoarse voice, difficulty swallowing or any digestive issues (nausea/vomiting, diarrhea, stomach pain)?

Have you been in close contact with a confirmed or probable case of COVID-19?

Date (YYYY-MM-DD)

Thank you for helping to protect our staff and students.