Swimming Pool COVID-19 Health Screening Questionnaire SWIMMING POOL COVID-19 HEALTH DECLARATION FORM This form MUST be submitted before your booked swimming time. Enter the date that is booked for swimming* MM slash DD slash YYYY Name of the person filling out this form* First Last I am submitting this form for:* myself (I am 16 years of age or older) my child If you are submitting for your child, please enter child's name. First Last Has the person entering the pool travelled outside of the province in the last 14 days?* Yes No Has the person entering the pool been in close contact with a known or suspected case of COVID-19?* Yes No Has the person entering the pool been in close contact with a person with acute respiratory illness who has travelled outside of Newfoundland and Labrador within 14 dyas prior to their illness onset?* Yes No Has the person entering the pool had any symptoms of the illness (as described below:*1. Fever or signs of a fever, such as chills, sweats, muscle aches, and lightheadedness) 2. Cough 3. Headache 4. Runny nose 5. Painful swallowing 6. Diarrhea 7. Loss of sense of smell or taste 8. Unexplained loss of appetite 9. Small red or purple spots on hands and/or feet? Yes No By checking the box below I acknowledge and confirm I and/or the child I am submitting on behalf of, is not experiencing any flu-like sypmtoms and agree to immediately report if symptoms occur.* I agree
