COVID SCREENING FORMPlease complete the COVID SCREENING FORM Date * MM DD YYYY Name * First Name Last Name Email *Visitors Only Phone *Visitors Only (###) ### #### Reason for Visit Have you received two doses of the COVID-19 vaccine? Yes No Do you or anyone in your household have severe difficulty breathing, chest pain, confusion or loss of consciousness? * Yes No Do you or anyone in your household have any of the following symptoms: * - fever or chills - new or worsening cough, - shortness of breath, - sore throat, - difficulty swallowing, - stuffy or congested nose, - decrease or loss of taste or smell, - pink eye, - headache, - digestive issues like nausea/vomiting, diarrhoea, stomach pain, - muscle aches, - extreme tiredness that is unusual, - falling down often, - sluggishness or lack of appetite? Yes No Have you travelled outside of Canada in the last 14 days? * Yes No Have you had close contact with a confirmed or probable case of COVID 19? * Yes No Have you been in close contact with a person with acute respiratory illness who has been to an impacted area for COVID-19 in the last 14 days? * Yes No If you have answered yes to any of the following, please stay home and self isolate. Contact the Ontario Telehealth number +1 866-797-0000. Record keeping is pursuant to all privacy laws and regulations. Information will only be shared with the proper authorities upon reasonable request. Thank you! Remember to wear your mask in the studio + sanitize your hands upon entry. For all questions regarding the health and safety protocols of Ward 1 Studios Inc., please contact Sandy Clipsham (sandy@ward1studios.com)
