TSSC Health Screening Questionnaire
Individuals must complete this questionnaire prior to arriving at a training session.

The answer to all questions must be “No” with the answer to the final question regarding vaccination status must be"Yes" in order to be permitted to a training session.

IMPORTANT: THIS MUST BE COMPLETED ON THE SAME DAY AS YOUR ARRIVAL.
Sign in to Google to save your progress. Learn more
First & Last Name *
Cell Phone Number *
Email address *
In the last 14 days, have you (or your child if you are doing this screening on their behalf) travelled outside of Canada?  If exempt from federal quarantine requirements (for example, you are fully vaccinated and have met the specific conditions, or an essential worker who crosses the Canada-US border regularly for work), select “No.” *
Has a doctor, health care provider, or public health unit told you (or your child if you are doing this screening on their behalf) that you should currently be isolating (staying at home)? This can be because of an outbreak, contact tracing, or after testing positive on a rapid antigen test. *
In the last 14 days, have you (or your child if you are doing this screening on their behalf) been identified as a “close contact” of someone who currently has COVID-19?  If you are fully vaccinated (it has been 14 or more days since your final dose of either a two-dose or a one-dose vaccine series) and have not been told to self-isolate by public health, select “No.” *
In the last 14 days, have you (or your child if you are doing this screening on their behalf) received a COVID Alert exposure notification on your cell phone?  If they already went for a test and got a negative result, select “No.”  If you are fully vaccinated (it has been 14 or more days since your final dose of either a two-dose or a one-dose vaccine series), select “No.” *
Are you (or your child if you are doing this screening on their behalf) currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have. *
Yes
No
Fever and/or chills (temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher)
Cough or barking cough/croup (continuous, more than usual, making a whistling noise when breathing; not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)
Shortness of breath, out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)
Decrease or loss of taste or smell (not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have)
Sore throat or difficulty swallowing; painful swallowing (not related to seasonal allergies, acid reflux, or other known causes or conditions you already have)
Runny or stuffy/congested nose (not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have)
Headache; unusual, long-lasting (not related to getting a COVID-19 vaccine in the last 48 hours, tension-type headaches, chronic migraines, or other known causes or conditions you already have)
Nausea, vomiting, and/or diarrhea or digestive issues (not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have)
Extreme tiredness or muscle aches or joint pain; unusual, fatigue, lack of energy, poor feeding in infants (not related to getting a COVID-19 vaccine in the last 48 hours, depression, insomnia, thyroid dysfunction, sudden injury, or other known causes or conditions you already have)
Pink eye/Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)
Falling down often (for older people)
Is anyone you live with (or your child lives with if you are doing this screening on their behalf) currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? If you are fully vaccinated (it has been 14 or more days since your final dose of either a two-dose or a one-dose vaccine series), select “No.”  If you got a COVID-19 vaccine in the last 48 hours and are experiencing a mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.” *
In the last 10 days, have you (or your child lives with if you are doing this screening on their behalf) tested positive on a rapid antigen test or home-based self-testing kit?  If you have since tested negative on a lab-based PCR test, select "No." *
Are you (or your child if they are 12 years of age or older and you are doing this screening on their behalf) fully vaccinated (including the 14-day period after receiving the completed dose), as per TSSC and OSSA's vaccination policies? *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy