Program Health Assessment Please enable JavaScript in your browser to complete this form.What Program(s) are you attending? *PLEASE SHOW THE COMPLETED SCREEN TO YOUR INSTRUCTOR AT THE BEGINNING OF CLASS. Date: *Who is this form being completed for? *Myself onlyMy ChildMy ChildrenName of Program Participant: *FirstLastName of Second Program Participant:FirstLastDo you, or anyone in your household, have any symptoms including: a fever greater than 38°C, cough, shortness of breath or difficulty breathing, sore throat or runny nose *YesNoDo you, or anyone in your household, have any symptoms including: chills, painful swallowing, stuffy nose, headache, muscle or joint ache, feeling unwell, fatigued, nausea, vomiting, diarrhea, unexplained loss of appetite, loss of sense of takes or smell, or conjunctivitis (commonly known as pink eye)? *YesNoIn the past 14 days, have you, or anyone in your household, been in close unprotected contact with someone who has tested positive for COVID-19? *YesNoIn the past 14 days, have you, or anyone in your household, returned from travel outside of Canada *YesNoDoes everyone in your cohort have a mask with them? * *YesNoPlease note: Masks are required for participants over the age of 2. Youth are not required to wear a mask when physically exerting themselves in the program activity. Comments: The information provided on this checklist is collected under the Personal Information and Privacy Act (PIPA) and will be used only for the purpose of providing Alberta Health Services attendee information if a potential exposure occurs onsite. You may complete one form per household/address.Submit