COVID-19 Screening Questionnaire

To prevent the spread of COVID-19, persons attending any programs at Trinity Placentia Stadium (e.g., participants, parents/guardians, delivery persons, guest speakers) should be pre-screened prior to entering. Leaders should retain all completed forms for 14 days.

Date:

Name:

Program Name:

Location: Trinity Placentia Stadium, Whitbourne

Self-Declaration by Program Participant/Visitor/Parent or Guardian

 Have you or anyone in your family (not including asymptomatic rotational workers):

• traveled in the last 14 days outside the Atlantic Provinces (New Brunswick, Nova Scotia, Prince Edward Island and Newfoundland and Labrador) or outside the communities along the Labrador-Quebec border (Labrador City, Wabush, Fermont, the Labrador Straits area and Blanc Sablon)?

___ Yes     ____ No

• been in close contact with a known or suspected case of COVID-19 in the last 14 days?

___ Yes     ____ No

• been in close contact, in the last 14 days, with a person suffering from acute respiratory illness who has travelled outside of the identified areas within 14 days prior to illness onset?

___ Yes     ___ No

• had two or more of the following symptoms (new or worsening) in the last 14 days:
• Fever (or signs of a fever, such as chills, sweats, muscle aches, and lightheadedness); cough; Headache; Sore throat; Runny nose;  Painful swallowing;  Diarrhea; Loss of sense of smell or taste; Unexplained loss of appetite; OR,  Small red or purple spots on your hands and/or feet?

___Yes     ___ No

I ________________________acknowledge and confirm that I/my child am/is not experiencing any

flulike symptoms and agree to immediately report, and call 811, if symptoms occur.

Signature: ____________________ Date: _____________________