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COVID SCREENING
Your Full Name *
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Above 10 years
Below 10
Total
Covid Status1
Covid Status1
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NAME
ABOVE 12
VACCINATED
Covid Questinaire - Answer Yes/No
Applicable for all accompanying Family
At Dumas We Concentrate our efforts to preventing the spread of the COVID-19, following the WHO Guidelines.
1. Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions.
Fever and/or chills,Cough or barking,cough, Shortness of breath, loss of smell or taste, Fatigue. lethargy, malaise and/or myalgias, Nausea, vomiting and/or diarrhea
2. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?
3. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing.
4. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19? If public health has advised you that you do not need to self-isolate (e.g., you are fully immunized* or have tested positive for COVID-19 in the last 90 days and since been cleared), select “No.”
5. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? If you have already gone for a test and got a negative result, select "No." If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No."
6. In the last 10 days, have you tested positive on a rapid antigen test or a home based self-testing kit? If you have since tested negative on a lab-based PCR test, select “No.”
7. In the last 14 days, has someone in your household (someone you live with) travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements) in the last 14 days? If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.”
8. In the last 10 days, has someone in your household (someone you live with) been identified as a ”close contact” of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self-isolate in the last 10 days? If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.”
9. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.” If you are fully vaccinated or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.”
I Agree that the above questions are applicable to me and my Family Accompanying me.
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