Staff Covid Screening COVID-19 SYMPTOM CHECKLIST FOR EMPLOYEES OF SPLASHVILLE INC. All employees must complete this questionnaire prior to each day of lessons: Entry Date: Do you have any of the following symptoms? Fever (greater than 38°) YesNo Cough YesNo Shortness of breath YesNo Sore throat YesNo Runny nose YesNo Has anyone in your household experienced any of the above symptoms in the last 14 days? YesNo Have you, or anyone in your household travelled outside of Canada in the last 14 days? YesNo Have you, or anyone in your household been in contact in the last 14 days with someone who is being investigated as a suspected case of COVID-19? YesNo Are you currently being investigated as a suspected case of COVID-19? YesNo Have you tested positive for COVID-19 within the last 10 days? YesNo **IF AN INDIVIDUAL ANSWERS “YES” TO ANY OF THE ABOVE QUESTIONS, THEY ARE NOT PERMITTED TO WORK IN ANY FORM FOR SPLASHVILLE INC. THIS WILL BE FOR A MINIMUM OF 14 DAYS, AND RETURN WITH A DOCTOR’S NOTE INFORMING A CLEAN BILL OF HEALTH. I hereby acknowledge that the above information is truthful. SUBMIT