Return to Training after a Failed Screening - Marcio Nunes Brazilian Jiu-Jitsu Academy

Name (Student)*

First Last

Name (Guardian - if applicable)

First Last

Date*

Screening Questions

1. Are you or anyone in your household currently experiencing any of these symptom?

Fever and/or chills*

Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Yes
No

Cough or barking cough (croup)*

Continuous, more than usual, making a whistling noise when breathing, not related to other known causes or conditions (for example, asthma, postinfectious reactive airways)

Yes
No

Shortness of breath*

Out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma

Yes
No

Decrease or loss of smell or taste*

Not related to other known causes or conditions (for example, allergies, neurological disorders)

Yes
No

2. Are you or anyone in your household currently experiencing any of these symptom?

Sore throat or difficulty swallowing*

Painful swallowing, not related to other known causes or conditions (for example, seasonal allergies, acid reflux)

Yes
No

Runny or stuffy/congested nose*

Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather)

Yes
No

Headache that’s unusual or long lasting*

Not related to other known causes or conditions (for example, tension-type headaches, chronic migraines)

Yes
No

Nausea, vomiting and/or diarrhea*

Not related to other known causes or conditions (for example, irritable bowel syndrome, anxiety in children, menstrual cramps)

Yes
No

Extreme tiredness that is unusual or muscle aches*

Fatigue, lack of energy, poor feeding in infants, not related to other known causes or conditions (for example, depression, insomnia, thyroid disfunction, sudden injury)

Yes
No

3. Have they travelled outside of Canada in the last 14 days?*

Yes
No

4. In the last 14 days, has a public health unit identified them as a close contact of someone who currently has COVID-19?*

Yes
No

5. Has a doctor, health care provider, or public health unit told them/you that they should currently be isolating (staying at home)?*

Yes
No

6. In the last 14 days, have they received a COVID Alert exposure notification on their cell phone?*

Yes
No

Results of Screening Questions

If you answered “YES” to any of the symptoms included under question 1:

Contact the gym to let them know about this result.
They should isolate (stay home) and not leave except to get tested or for a medical emergency.
Talk with a doctor/health care provider to get advice or an assessment, including if they need a COVID-19 test and how long they should isolate.
Household members without symptoms may NOT go to the gym.
There is the option to do all of our classes virtually if the student is feeling well enough.

If you answered “YES” to only one of the symptoms included under question 2:

Contact the gym to let them know about this result.
They should isolate (stay home) for at least 24 hours and not leave except for a medical emergency.
Wait 24 hours after their symptom has resolved, at this point they can return to the gym when they feel well enough to go. They do not need to get tested.
Household members without symptoms may NOT go to the gym.
There is the option to do all of our classes virtually if the student is feeling well enough.

If you answered “YES” to two or more of the symptoms included under question 2:

Contact the gym to let them know about this result.
They should isolate (stay home) and not leave except to get tested or for a medical emergency.
Talk with a doctor/health care provider to get advice or an assessment, including if they need a COVID-19 test.
Household members without symptoms may NOT go to the gym.
There is the option to do all of our classes virtually if the student is feeling well enough.

If you answered “YES” to question 3, 4, 5 or 6:

Contact the gym to let them know about this result.
They should isolate (stay home) for 14 days and not leave except to get tested or for a medical emergency.
Talk with a doctor/health care provider to get advice or an assessment, including if they need a COVID-19 test.

If you answered “NO” to all questions, your child may go to the gym.

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