CPCC Staff Screening Form
This questionnaire is to be completed by all staff before entering the Carleton Place Canoe Club site. If the answer to any of the following questions is YES, staff will NOT be permitted to attend the Canoe Club.
Email address *
Date (of participation): *
Staff Last Name: *
Staff First Name: *
Do you, or any members of your household, have any of the following symptoms: Fever, new onset of cough, worsening chronic cough, shortness of breath, difficulty breathing, sore throat, difficulty swallowing, loss of smell or taste, chills, headaches, unexplained fatigue or muscle aches, nausea, diarrhea, abdominal pain, pink eye, runny nose or nasal congestion without other known cause? *
Have you traveled outside of Canada in the last 14 days? *
Have you tested positive with, or been in contact with a confirmed or probable case of COVID-19 without wearing appropriate PPE? *
Have you taken any fever reducing medication in the last 5 hours? *
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