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 *
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DD
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Teacher(s) of today’s dance class(es) *
Required
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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