COVID-19 Self Assessment Tool

Client Name *

First

Last

Therapist *

Kara Broks
Heather Tremblay
Danae Burke
Hailey Richards
Jessica Liao
Grad Student Session
Jenna Wiltzen
Julia Halford

Do YOU or ANYONE YOU HAVE BEEN IN CONTACT WITH have any of the following - click all that apply or none of the above *

Please choose all that apply

In the last 14 days, have YOU or ANYONE YOU HAVE BEEN IN CONTACT WITH been tested for COVID-19? *

Yes
No

In the last 14 days have YOU or ANYONE YOU HAVE BEEN IN CONTACT WITH returned from out of province travel? *

Yes
No

Please note, answering YES does not prevent you from attending your scheduled appointment.

Have you traveled to or visited any area of Saskatchewan that Public Health has deemed an outbreak area or has an elevated risk for acquiring Covid-19 within the past 14 days? *

Yes
No

Please note, answering YES does not prevent you from attending your scheduled appointment. **Here is the link for the current SK Health Outbreak List in Saskatchewan https://www.saskatchewan.ca/government/health-care-administration-and-provider-resources/treatment-procedures-and-guidelines/emerging-public-health-issues/2019-novel-coronavirus/latest-updates/covid-19-active-outbreaks#south-outbreaks

CORONAVIRUS (COVID-19): The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization and COVID-19 is extremely contagious. The Speech Language Network has put in place preventative measures to reduce the spread of COVID-19; however, The Speech Language Network cannot guarantee that you or your child will not become infected with COVID-19. Furthermore, the client/family and therapist will collaboratively decide best PPE implementation for the client’s specific needs. By checking yes, you acknowledge you are aware of the risks, dangers and hazards, and that you are participating in therapy services at the Speech Language Network. Further details of enhanced protocols and guidelines to ensure the safety of our staff and can be found at www.thesln.com/clinic-policies .

Do you acknowledge that there may be risks involved (related to COVID-19) while participating in therapy services at the Speech Language Network? *

Yes
No

Please solve to submit this form. ( The * symbol indicates multiplication). *

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