Session Screening Checklist (adult)

*This form will be updated to reflect any Government of Alberta and Alberta Health Services changes to questions and requirements.

Due to the Coronavirus (COVID-19) outbreak we are taking extra precautions with the care of every member to include session tracking, social distancing protocols and enhanced sanitation/disinfection procedures in accordance with the Alberta Heather Services. This form MUST be filled out EVERY SESSION. 

I understand/agree that by answering YES to any of the following questions, on any given day throughout the above noted session, the participant noted above is required to remain home and will NOT be allowed to participate in any training sessions, camps, or any other activities.

1. Do you have any of the below symptoms: 

• Fever (greater than 38.0C)
   YES  NO
   
• Cough
   YES  NO
   
• Shortness of Breath / Difficulty Breathing
   YES  NO
   
• Sore throat
   YES  NO
   
• Chills
   YES  NO
   
• Painful swallowing
   YES  NO
   
• Runny Nose/Nasal Congestion
   YES  NO
   
• Feeling unwell/Fatigued
   YES  NO
   
• Nausea/ Vomiting/ Diarrhea
   YES  NO
   
• Unexplained loss of appetite
   YES  NO
   
• Loss of sense of taste or smell
   YES  NO
   
• Muscle / Joint aches
   YES  NO
   
• Headache
   YES  NO
   
• Conjunctivitis
   YES  NO

2. Has the attendee travelled outside of Canada in the last 14 days?
  YES  NO

3. Has the attendee had close contact* with a confirmed case of COVID-19 in the last 14 days?
  YES  NO

4. Has the attendee had close contact with a symptomatic** close contact of a confirmed case of COVID-19 in the last 14 days?
  YES  NO

*Face-to-face contact within 2 metres. A health care worker in a occupational setting wearing the recommended personal protective equipment is not considered to be a close contact.
**’Ill/symptomatic’ means someone with COVID-19 symptoms on the list above. 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. 

If the participant arrives exhibiting any of the above symptoms, staff has the right to refuse entry into the facility. If the participant develops any of the above symptoms, staff will implement their rapid response to symptomatic individuals’ policy.

I understand that coaches, employees, or volunteers cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each participant.