Scouts COVID-19 Self Assessment Form

Parents/guardians/youth must use this questionnaire before participating in any Scouting activity to decide whether the youth should attend.

Today's Date

Date

Attendees Name*

First NameLast Name

Scouts Canada Section or Role

Are you experiencing symptoms* of COVID-19?*

YESNO

Have you, or anyone in your household, returned from travel outside of Canada within the last 14 days?*

YESNO

Are you experiencing symptoms* of COVID-19?*

YESNO

Have you or any household members had unshielded** contact with someone who is ill with a cough and/or fever?*

YESNO

Have you or anyone in your household had unshielded contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?*

YESNO

*It is understood that some allergies or pre-existing conditions may express similar symptoms to COVID-19. If in doubt consult a medical professional. Please discuss participation with your Section Contact Scouter or Group Commissioner before attending Scouting. If in doubt don’t Scout.

*“Unshielded” means close contact (with two metres) without the use of appropriate personal protective equipment (PPE).

If you have answered “YES” to any of the above questions, please DO NOT attend the Scouting activity at this time. You should stay home and determine whether you need to be tested for COVID-19.

If you have answered “NO” to all the above questions, you may participate in the Scouting activity.

Parent/Guardian or Adult Signature

SELF-ASSESSMENT SCREENING CHECKLIST