HCA Covid-19 Pre-Entry Survey

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All students and staff members must complete a pre-screening survey online each time prior to entering the building. Students will not be permitted to participate in group or private lessons until a parent/guardian has successfully completed the survey.

Please note: It must be completed the DAY OF each class to be valid.

Last Name* *

First Name *

In the last 5 days does the student/staff member, or anyone in your household, have any of the following symptoms? *

Fever (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher)

Shortness of breath (out of breath, unable to breathe deeply)

None of the above

Required

Does the student/staff member have any of the following symptoms? *

Barking cough (making a squeaky or whistling noise when breathing)

Chills

Sore throat or difficulty swallowing

Runny, stuffy or congested nose (unrelated to seasonal allergies or other known causes/conditions)

Lost sense of taste or smell

Headache that’s unusual or long lasting

Digestive issues like nausea/vomiting, diarrhea, stomach pain unrelated to known cause or condition

Extreme tiredness (fatigue, lack of energy)

Falling down often

Muscle aches that are unusual or long lasting

Pinkeye (conjunctivitis)

Sluggishness or lack of appetite

None of the above

Required

In the last 14 days have you travelled outside of Canada and were told to quarantine or told to not attend school/child care or someone you live with returned from outside Canada and is isolating while waiting for COVID-19 test results? *

Yes

Have you been identified as a “close contact” of someone who currently has COVID-19 and been advised to self-isolate? *

Yes

Are you or any member of your household awaiting the results of a COVID-19 test? *

Yes

Do you live with someone who is currently isolating because of COVID-19 symptoms or a positive COVID-19 test? *

Yes

In the last 5 days, have you tested positive for COVID-19? Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *

Yes

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