Persian School COVID-19 Screening Questionnaire Please enable JavaScript in your browser to complete this form.1. Please provide your full name *FirstLast2. Phone number *3. Email address *4. Who is your contact person at persian school? *5. Which level are you attending? *ElementaryIntermediateAdvancedAdult 18 and above6. Please select if you have any of the following new or worsening symptoms or signs: * Fever or chillsDifficulty breathing or shortness of breathCoughSore throat, trouble swallowingRunny nose/stuffy nose or nasal congestionDecrease or loss of smell or tasteNausea, vomiting, diarrhea, abdominal painPink eyeHeadache that is unusual or long lastingMuscle aches or tiredness that is unusual or long lastingNon of the above7. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *YesNo8. In the last 14 days, have you travelled outside of Canada and been told to quarantine (per the federal quarantine requirements)? *YesNo9. In the last 14 days, has a public health unit identified you as a close contact of someone who currently has COVID-19? *YesNo10. In the last 10 days, have you tested positive on a rapid antigen test or home-based self testing kit? *YesNo11. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *YesNo12. In the last 14 days, have you received a COVID Alert exposurevnotification on your cellphone? (If you already went for a test and got a negative result, select "No".) *YesNo13. If you answered YES to any of the questions listed above, please do NOT enter the class and notify your contact person at the Persion School as soon as possible (via phone or email) to determine the next steps. Please note: Persion Scool reserves the right to request clearance (medical or Public health) in the event of direct exposure or a probable/positive case of COVID-19.I understand the above and I did not answer yesto any questions above. I will be entering the class.I understand the above . I DID answer YES and I will be notifying my contact at the Persian School.14. Upon visiting the Persian school classes, you agree to abide by all Health and safety measures implemented by the Persian School as outlined here: visitors are required to sanitize their hands prior to entering the classes. Visitors are also required to wear face masks throughout their visit. *I understand15. Please click below *I attest that all the information above is accurateSubmit
