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Daily Screening Checklist
*Will be updated to reflect any Government of Alberta and Alberta Health Services changes to questions and requirements.

Today's Date: July 4, 2020

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Activity/Group Name

Activity Start Time

Do you have any of the below symptoms: 

Fever (greater than 38.0C)*
No
Yes
Cough*
No
Yes
Shortness of Breath / Difficulty Breathing*
No
Yes
Sore throat*
No
Yes
Chills*
No
Yes
Painful swallowing*
No
Yes
Runny Nose/Nasal Congestion*
No
Yes
Feeling unwell/Fatigued*
No
Yes
Nausea/ Vomiting/ Diarrhea*
No
Yes
Unexplained loss of appetite*
No
Yes
oss of sense of taste or smell*
No
Yes
Muscle / Joint aches*
No
Yes
Headache*
No
Yes
Conjunctivitis*
No
Yes
Have you, or anyone in your household travelled outside of Canada in the last 14 days?*
No
Yes
Have you or your children attending the program had close unprotected contact (face-to-face contact within two-meters) with someone who is ill with cough and/or fever?*
No
Yes
Have you or anyone in household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?*
No
Yes

*If the participant has answered "YES" to any of the above questions do not participate. Proceed home and use the AHS Online Assessment Tool to determine if testing is recommended. 

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Activity/Group Name

Activity Start Time

Do you have any of the below symptoms: 

Fever (greater than 38.0C)*
No
Yes
Cough*
No
Yes
Shortness of Breath / Difficulty Breathing*
No
Yes
Sore throat*
No
Yes
Chills*
No
Yes
Painful swallowing*
No
Yes
Runny Nose/Nasal Congestion*
No
Yes
Feeling unwell/Fatigued*
No
Yes
Nausea/ Vomiting/ Diarrhea*
No
Yes
Unexplained loss of appetite*
No
Yes
oss of sense of taste or smell*
No
Yes
Muscle / Joint aches*
No
Yes
Headache*
No
Yes
Conjunctivitis*
No
Yes
Have you, or anyone in your household travelled outside of Canada in the last 14 days?*
No
Yes
Have you or your children attending the program had close unprotected contact (face-to-face contact within two-meters) with someone who is ill with cough and/or fever?*
No
Yes
Have you or anyone in household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?*
No
Yes

*If the participant has answered "YES" to any of the above questions do not participate. Proceed home and use the AHS Online Assessment Tool to determine if testing is recommended. 

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Activity/Group Name

Activity Start Time

Do you have any of the below symptoms: 

Fever (greater than 38.0C)*
No
Yes
Cough*
No
Yes
Shortness of Breath / Difficulty Breathing*
No
Yes
Sore throat*
No
Yes
Chills*
No
Yes
Painful swallowing*
No
Yes
Runny Nose/Nasal Congestion*
No
Yes
Feeling unwell/Fatigued*
No
Yes
Nausea/ Vomiting/ Diarrhea*
No
Yes
Unexplained loss of appetite*
No
Yes
oss of sense of taste or smell*
No
Yes
Muscle / Joint aches*
No
Yes
Headache*
No
Yes
Conjunctivitis*
No
Yes
Have you, or anyone in your household travelled outside of Canada in the last 14 days?*
No
Yes
Have you or your children attending the program had close unprotected contact (face-to-face contact within two-meters) with someone who is ill with cough and/or fever?*
No
Yes
Have you or anyone in household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?*
No
Yes

*If the participant has answered "YES" to any of the above questions do not participate. Proceed home and use the AHS Online Assessment Tool to determine if testing is recommended. 

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Activity/Group Name

Activity Start Time

Do you have any of the below symptoms: 

Fever (greater than 38.0C)*
No
Yes
Cough*
No
Yes
Shortness of Breath / Difficulty Breathing*
No
Yes
Sore throat*
No
Yes
Chills*
No
Yes
Painful swallowing*
No
Yes
Runny Nose/Nasal Congestion*
No
Yes
Feeling unwell/Fatigued*
No
Yes
Nausea/ Vomiting/ Diarrhea*
No
Yes
Unexplained loss of appetite*
No
Yes
oss of sense of taste or smell*
No
Yes
Muscle / Joint aches*
No
Yes
Headache*
No
Yes
Conjunctivitis*
No
Yes
Have you, or anyone in your household travelled outside of Canada in the last 14 days?*
No
Yes
Have you or your children attending the program had close unprotected contact (face-to-face contact within two-meters) with someone who is ill with cough and/or fever?*
No
Yes
Have you or anyone in household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?*
No
Yes

*If the participant has answered "YES" to any of the above questions do not participate. Proceed home and use the AHS Online Assessment Tool to determine if testing is recommended. 

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Activity/Group Name

Activity Start Time

Do you have any of the below symptoms: 

Fever (greater than 38.0C)*
No
Yes
Cough*
No
Yes
Shortness of Breath / Difficulty Breathing*
No
Yes
Sore throat*
No
Yes
Chills*
No
Yes
Painful swallowing*
No
Yes
Runny Nose/Nasal Congestion*
No
Yes
Feeling unwell/Fatigued*
No
Yes
Nausea/ Vomiting/ Diarrhea*
No
Yes
Unexplained loss of appetite*
No
Yes
oss of sense of taste or smell*
No
Yes
Muscle / Joint aches*
No
Yes
Headache*
No
Yes
Conjunctivitis*
No
Yes
Have you, or anyone in your household travelled outside of Canada in the last 14 days?*
No
Yes
Have you or your children attending the program had close unprotected contact (face-to-face contact within two-meters) with someone who is ill with cough and/or fever?*
No
Yes
Have you or anyone in household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?*
No
Yes

*If the participant has answered "YES" to any of the above questions do not participate. Proceed home and use the AHS Online Assessment Tool to determine if testing is recommended. 

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Activity/Group Name

Activity Start Time

Do you have any of the below symptoms: 

Fever (greater than 38.0C)*
No
Yes
Cough*
No
Yes
Shortness of Breath / Difficulty Breathing*
No
Yes
Sore throat*
No
Yes
Chills*
No
Yes
Painful swallowing*
No
Yes
Runny Nose/Nasal Congestion*
No
Yes
Feeling unwell/Fatigued*
No
Yes
Nausea/ Vomiting/ Diarrhea*
No
Yes
Unexplained loss of appetite*
No
Yes
oss of sense of taste or smell*
No
Yes
Muscle / Joint aches*
No
Yes
Headache*
No
Yes
Conjunctivitis*
No
Yes
Have you, or anyone in your household travelled outside of Canada in the last 14 days?*
No
Yes
Have you or your children attending the program had close unprotected contact (face-to-face contact within two-meters) with someone who is ill with cough and/or fever?*
No
Yes
Have you or anyone in household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?*
No
Yes

*If the participant has answered "YES" to any of the above questions do not participate. Proceed home and use the AHS Online Assessment Tool to determine if testing is recommended. 

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Activity/Group Name

Activity Start Time

Do you have any of the below symptoms: 

Fever (greater than 38.0C)*
No
Yes
Cough*
No
Yes
Shortness of Breath / Difficulty Breathing*
No
Yes
Sore throat*
No
Yes
Chills*
No
Yes
Painful swallowing*
No
Yes
Runny Nose/Nasal Congestion*
No
Yes
Feeling unwell/Fatigued*
No
Yes
Nausea/ Vomiting/ Diarrhea*
No
Yes
Unexplained loss of appetite*
No
Yes
oss of sense of taste or smell*
No
Yes
Muscle / Joint aches*
No
Yes
Headache*
No
Yes
Conjunctivitis*
No
Yes
Have you, or anyone in your household travelled outside of Canada in the last 14 days?*
No
Yes
Have you or your children attending the program had close unprotected contact (face-to-face contact within two-meters) with someone who is ill with cough and/or fever?*
No
Yes
Have you or anyone in household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?*
No
Yes

*If the participant has answered "YES" to any of the above questions do not participate. Proceed home and use the AHS Online Assessment Tool to determine if testing is recommended. 

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Activity/Group Name

Activity Start Time

Do you have any of the below symptoms: 

Fever (greater than 38.0C)*
No
Yes
Cough*
No
Yes
Shortness of Breath / Difficulty Breathing*
No
Yes
Sore throat*
No
Yes
Chills*
No
Yes
Painful swallowing*
No
Yes
Runny Nose/Nasal Congestion*
No
Yes
Feeling unwell/Fatigued*
No
Yes
Nausea/ Vomiting/ Diarrhea*
No
Yes
Unexplained loss of appetite*
No
Yes
oss of sense of taste or smell*
No
Yes
Muscle / Joint aches*
No
Yes
Headache*
No
Yes
Conjunctivitis*
No
Yes
Have you, or anyone in your household travelled outside of Canada in the last 14 days?*
No
Yes
Have you or your children attending the program had close unprotected contact (face-to-face contact within two-meters) with someone who is ill with cough and/or fever?*
No
Yes
Have you or anyone in household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?*
No
Yes

*If the participant has answered "YES" to any of the above questions do not participate. Proceed home and use the AHS Online Assessment Tool to determine if testing is recommended. 

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Activity/Group Name

Activity Start Time

Do you have any of the below symptoms: 

Fever (greater than 38.0C)*
No
Yes
Cough*
No
Yes
Shortness of Breath / Difficulty Breathing*
No
Yes
Sore throat*
No
Yes
Chills*
No
Yes
Painful swallowing*
No
Yes
Runny Nose/Nasal Congestion*
No
Yes
Feeling unwell/Fatigued*
No
Yes
Nausea/ Vomiting/ Diarrhea*
No
Yes
Unexplained loss of appetite*
No
Yes
oss of sense of taste or smell*
No
Yes
Muscle / Joint aches*
No
Yes
Headache*
No
Yes
Conjunctivitis*
No
Yes
Have you, or anyone in your household travelled outside of Canada in the last 14 days?*
No
Yes
Have you or your children attending the program had close unprotected contact (face-to-face contact within two-meters) with someone who is ill with cough and/or fever?*
No
Yes
Have you or anyone in household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?*
No
Yes

*If the participant has answered "YES" to any of the above questions do not participate. Proceed home and use the AHS Online Assessment Tool to determine if testing is recommended. 

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Activity/Group Name

Activity Start Time

Do you have any of the below symptoms: 

Fever (greater than 38.0C)*
No
Yes
Cough*
No
Yes
Shortness of Breath / Difficulty Breathing*
No
Yes
Sore throat*
No
Yes
Chills*
No
Yes
Painful swallowing*
No
Yes
Runny Nose/Nasal Congestion*
No
Yes
Feeling unwell/Fatigued*
No
Yes
Nausea/ Vomiting/ Diarrhea*
No
Yes
Unexplained loss of appetite*
No
Yes
oss of sense of taste or smell*
No
Yes
Muscle / Joint aches*
No
Yes
Headache*
No
Yes
Conjunctivitis*
No
Yes
Have you, or anyone in your household travelled outside of Canada in the last 14 days?*
No
Yes
Have you or your children attending the program had close unprotected contact (face-to-face contact within two-meters) with someone who is ill with cough and/or fever?*
No
Yes
Have you or anyone in household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?*
No
Yes

*If the participant has answered "YES" to any of the above questions do not participate. Proceed home and use the AHS Online Assessment Tool to determine if testing is recommended. 

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Activity/Group Name

Activity Start Time

Do you have any of the below symptoms: 

Fever (greater than 38.0C)*
No
Yes
Cough*
No
Yes
Shortness of Breath / Difficulty Breathing*
No
Yes
Sore throat*
No
Yes
Chills*
No
Yes
Painful swallowing*
No
Yes
Runny Nose/Nasal Congestion*
No
Yes
Feeling unwell/Fatigued*
No
Yes
Nausea/ Vomiting/ Diarrhea*
No
Yes
Unexplained loss of appetite*
No
Yes
oss of sense of taste or smell*
No
Yes
Muscle / Joint aches*
No
Yes
Headache*
No
Yes
Conjunctivitis*
No
Yes
Have you, or anyone in your household travelled outside of Canada in the last 14 days?*
No
Yes
Have you or your children attending the program had close unprotected contact (face-to-face contact within two-meters) with someone who is ill with cough and/or fever?*
No
Yes
Have you or anyone in household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?*
No
Yes

*If the participant has answered "YES" to any of the above questions do not participate. Proceed home and use the AHS Online Assessment Tool to determine if testing is recommended. 

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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