Daily COVID19 Self Assessment Questionnaire

Daily COVID19 Self Assessment Questionnaire

Covid-19 Declaration - Survey Must be Completed by 4:30 p.m. Daily on Training Days
Name *

First Name Last Name
Phone Number *
Email *
example@example.com
Birth Date *

Month Day Year
Location of Training *
Age Group *
Date of Attendance *
Time *

: Hour Minutes AM/PM Option
1. Are you experiencing any of these COVID-19 like symptoms, that are not a result of an underlying pre-existing health condition: cough, fever, shortness of breath or difficulty breathing, runny and/or stuffy nose, sore throat, trouble swallowing, decrease or loss of smell or taste, nausea, vomiting, diarrhea, abdominal pain, not feeling well, extreme tiredness or sore muscles, chills, headache, dizziness, confusion, muscle or joint aches, skin rashes or discoloration of fingers/toes, conjunctivitis commonly known as pink eye? If you answer “yes”, please advise Sandra Colica , Sergio De Luca and your coach as per Ontario Public Health order, you must self-isolate for a minimum of 14 days from the start of symptoms. You must not come to training *

YES NO
2. Have you had close contact with a confirmed or probable case of Covid-19 in the last 14 days? *

YES NO
3. Have you travelled outside of Canada in the past 14 days? *

YES NO
Signature

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