SCREENING CHECKLIST
Attendees should fill out this checklist prior to participating in the activity or program. If an individual answers YES to any of the questions, they must not be allowed to attend or participate in the activity or program. Children and youth will need a parent to assist them to complete this screening tool.
Email *
Today's Date *
MM
/
DD
/
YYYY
Swimmer Name *
Swim Group *
1 point
List of car pool cohorts driving with your child today, to including pick-up & drop off drivers: *
Has your child, traveled outside Canada in the last 14 days? When entering or returning to Alberta from outside Canada, individuals are legally required to quarantine for 14 days unless enrolled in the Alberta COVID-19 International Border Pilot Project *
1 point
Has your child had close contact with a case of COVID-19 in the last 14 days? Face-to-face contact within 2 metres for 15 minutes or longer, or direct physical contact such as hugging *
1 point
If the child...
answered “YES” to any of the above:
 The child is required to quarantine for 14 days from the last day of exposure.
o If the child is participating in the Alberta COVID-19 International Border Pilot

Project, they must comply with the program restrictions at all times.
 If the child develops any symptoms, use the AHS Online Assessment Tool or call Health Link
811 to determine if testing is recommended.
If the child answered “NO” to both of the above:
 Proceed
Do you/your child have any new onset (or worsening) of any of the symptoms: *
4 points
Yes
No
Fever
Cough
Shortness of Breath / Difficulty Breathing
Loss of sense of taste or smell
If the child answered...
“YES” to any symptom in question 2:
 The child is to isolate for 10 days from onset of symptoms.
 Use the AHS Online Assessment Tool or call Health Link 811 to arrange for testing and to
receive additional information on isolation.
If the child answered “NO” to all of the symptoms in question 2:
 Proceed
Do you/your child have any new onset (or worsening) of any of the symptoms: *
9 points
Yes
No
Chills
Sore Throat / painful swallowing
Runny nose / congestion
Feeling unwell / fatigued
Nausea, vomiting, and/or diarrhea
Unexplained loss of appetite
Muscle / joint aches
Headache
Conjunctivitis (pink eye)
If the child answered....
“YES” to ONE symptom in question 3:
 Keep your child home and monitor for 24 hours.
 If their symptom is improving after 24 hours, they can return to school and activities
when they feel well enough to go. Testing is not necessary.
 If the symptom does not improve or worsens after 24 hours (or if additional symptoms
emerge), use the AHS Online Assessment Tool or call Health Link 811 to check if testing is recommended.
If the child answered “YES” to TWO OR MORE symptoms in question 3:
 Keep your child home.
 Use the AHS Online Assessment Tool or call Health Link 811 to determine if testing is
recommended.
 Your child can return to school and activities once their symptoms go away as long as it
has been at least 24 hours since their symptoms started.
If the child answered “NO” to all questions:
 Your child may attend school, child care and/or other activities.
CONSENT *
Required
A copy of your responses will be emailed to the address you provided.
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