Pre-Course COVID-19 Self Assessment Help Keep Everyone Safe To create a safe environment and reduce the potential risk of exposure to students and staff, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and others during your class. Note that this self-assessment tool is intended for COVID-19 only. Your symptoms may not be related to COVID-19 and could require you to seek medical attention. If you are uncertain and/or feel very sick, contact your family doctor/nurse practitioner or call 8-1-1. Are you experiencing any of the following symptoms? Answers to all symptoms are required. Severe difficulty breathing (e.g., struggling to breathe or speaking in single words) YesNo Severe chest pain YesNo Having a very hard time waking up YesNo Feeling confused YesNo Losing consciousness YesNo Mild to moderate shortness of breath YesNo Inability to lie down because of difficulty breathing YesNo Chronic health conditions that you are having difficulty managing because of difficulty breathing YesNo Please indicate if you are experiencing cold, flu or COVID-19-like symptoms, even mild ones. Fever Fever: Average normal body temperature taken orally is about 37°C. For more on normal body temperature and fevers, see Health Link BC's information for children age 11 and younger and for people age 12 and older. YesNo Chills YesNo Shortness of breath YesNo Loss of sense of smell or taste YesNo Fatigue YesNo Loss of appetite YesNo Nausea and vomiting YesNo Muscle aches YesNo Cough or worsening of chronic cough YesNo Sore throat YesNo Difficulty swallowing YesNo Stuffy or runny nose YesNo Headache YesNo Diarrhea YesNo Dizziness YesNo Confusion YesNo Abdominal Pain YesNo Skin rash YesNo Discoloration of fingers and toes YesNo Conjunctivitis (Pink eye) YesNo Have you travelled to any countries outside Canada (including the United States) within the last 14 days? YesNo Within the last 14 days did you provide care or have close contact with a symptomatic person known or suspected to have COVID-19? Note: This means you would have been contacted by your health authority’s public health team. YesNo Choose the course you're attending: (required) —Please choose an option—Standard First Aid CPR-C/AED (Blended)Emergency First Aid CPR-C/AED (OFA level 1 equivalent) (Blended)Emergency Child Care CPR-B/AEDCPR-C (Blended)CPR-A (Blended)BLS (HCP)Babysitter (Virtual) Course Date: (required) Participant Name: (required) Signed Date (the date you complete this form): (required) Your Email: (required) SIGNATURE: Enter your name here to confirm all of the information you provided is truthful: (required) [There can be a delay in form submission. Please only submit form once. Thank you.] NOTE: If you answered yes to any of the above questions, please DO NOT submit this form. Instead please contact us to reschedule. You will be asked these questions again before entering the building at your classroom location on day of your course. Thanks for your cooperation to keep everyone safe.
