Required COVID Screening Questions
Following questions will be asked for all individuals entering Pei-Chen's Studio. Please fill one form per person.
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When entering the studio please:
1. Take off shoes at the entrance.
2. Allow your teacher to temperature check using the Forehead Thermometer.
3. Continue to wear a mask for the full duration of the lesson.
4. Thoroughly wash hands with soap, then dry hands with paper towel. Discard the paper towel in the garbage bin right beside.
5. Avoid touching face during the lesson.
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Student's Name *
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, troubling swallowing *
Runny nose/stuffy nose or nasal congestion
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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 Atlantic Canada in the past 14 days and/or been in close contact with anyone who has? *
3. Have you had close contact with a confirmed or probable case of COVID-19? Close contact means: being less than 2m away in the same room, workspace, or area for over 15min | Living in the same home *
4. Have you been diagnosed with COVID-19 in the last 14 days? *
5. Have you visited/worked in any locations during a time identified as a known potential COVID exposure? *
I solemnly and sincerely declare that the information I have provided is true and correct and as I make this solemn declaration conscientiously believing the same to be true. If any person should suffer as a result of the information being found to be untrue and false, then I am aware I can be prosecuted for making a false declaration. If either I or someone I have been in contact with tests positive for covid-19 I will inform you. *
If you have answered YES or MAYBE to any of the questions, please stay home and take the online lesson.  Thank you for your understanding and cooperation.
Parent/Guardian Initial
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