Barvinok: Weekly COVID Screening
This tool has been developed to reduce the risk of transmission of COVID-19 among dancers, their families, and all Barvinok staff. This tool is meant to be used to assist with assessing those attending dance, who may be symptomatic, or who may have been exposed to someone who is ill or has confirmed COVID-19.

Attendees MUST fill out this checklist every Thursday before arriving at St. Vlad's. Those in the Adult Class must do this each Sunday and all senior level dancers Monday AND Thursday. If an individual answers YES to any of the questions, they MUST NOT be allowed to attend dance. Some children and youth may need a parent to assist them to complete this screening tool.

As the COVID-19 pandemic continues to evolve, the screening tool with be updated as required.
Dancer First and Last Name: *
Who is the dancer's teacher?
Does the dancer have any of the following symptoms: fever, cough, shortness of breath / difficulty breathing, sore throat, chills, painful swallowing, runny nose / nasal congestion, feeling unwell / fatigued, nausea / vomiting / diarrhea, unexplained loss of appetite, loss of taste or smell, muscle / joint aches, headache, conjunctivitis (pink eye) *
Has the dancer travelled outside Canada in the last 14 days? *
Has the dancer had close contact* with with a confirmed case of COVID-19 in the last 14 days? (* face-to-face within 2 metres) *
Will this dancer be attending dance tonight? *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy