5678 Dancer Screening Tool
To stop the spread of COVID19, dancers are required to use the self-screening tool below. A copy of this questionnaire will be sent to COVID19@5678dancestudio.com for our records to aid contact tracing and in keeping with the COVID19 guidelines outlined by the Ministry of Health Ontario. This questionnaire must be completed prior to a dancer’s entry into the dance studio.

The form is also available as a PDF for increased accessibility (https://5678dancestudio.com/wp-content/uploads/2020/11/5678-Dancer-Screening-Tool.pdf). Dancers choosing to submit their questionnaire this way should fill out their form, take a photo of it and email it to: COVID19@5678dancestudio.com prior to entering the facility. Please note, the form must be completed every time a dancer enters the facility and must have unique dates and teacher fields. Thank you for your cooperation.
Dancer's name *
Responsible adult filling out form (if dancer is a child):
Date *
Teacher(s) of today’s dance class(es) *
1. Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.
Fever or chills *
Difficulty breathing or shortness of breath *
Cough *
Sore throat, trouble swallowing *
Runny nose/stuffy nose or nasal congestion *
Decrease or loss of smell or taste *
Nausea, vomiting, diarrhea, abdominal pain *
Not feeling well, extreme tiredness, sore muscles *
2. Have you travelled outside of Canada in the past 14 days? *
3. Have you had close contact with a confirmed or probable case of COVID-19? *
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