RH Studio COVID-19 Safety Form | RocketHouse

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RocketHouse Studio COVID-19 Check-in Form

To be completed 24-48 hours before arrival at RocketHouse Studio. This form will take approximately 5 minutes to complete.

Step 1 of 5

20%

Basic Information
Today's Date*
YYYY dash MM dash DD
Name*
First Last
Company Name
Mobile Phone*
Email*
Are you 18 years of age or older?*
- Yes
- No
Guardian / Parent's Name*
First Last
This person is responsible for your safety at all times and must remain onsite with you throughout the production. Your guardian must also fill out a RocketHouse Studio COVID safety form of their own.
Guardian / Parent Phone*
Guardian / Parent Email*

Production Information
Name of Production or Digital Event*
Filming Date*
YYYY dash MM dash DD
Your Role On Site*
- On-camera (host, guest, panellist, instructor)
- Client Representative
- RocketHouse Staff

COVID-19 Test & Quarantine Checklist
Have you travelled outside of Canada in the last 14 days?*
- Yes
- No
Have you travelled outside of Alberta in the last 14 days?*
- Yes
- No
Have you had close contact with a case of COVID-19 in the last 14 days?*
- Yes
- No
"Close Contact" is defined by the Alberta Government as face-to-face contact within 2 metres (with or without masks). A health care worker in an occupational setting wearing recommended personal protective equipment is not considered a close contact. "Confirmed Case" is defined as a lab-confirmed case OR a probable case as defined in the Alberta COVID-19 Notifiable Disease Guideline. (Links at bottom of page.)
Have you been tested for COVID-19 in the last four (4) weeks?*
- Yes
- No
On what date were you most recently tested for COVID-19?*
YYYY dash MM dash DD
If Yes, what were the results of your most recent COVID-19 test?*
- Positive
- Negative
- Results Pending
Please explain the reason for your most recent COVID-19 test.
Example: Close contact, onset of symptoms, travel, requirement of job, I am a healthcare worker, I am a caregiver, etc.
Are you currently required by provincial or federal health regulations to be under quarantine?*
- Yes
- No
If Yes, what is the reason for your quarantine?
Example: Close contact, onset of symptoms, travel, etc.
On what date is your quarantine scheduled to end?
YYYY dash MM dash DD

COVID-19 Vaccination
Have you received a vaccination for COVID-19?*
- Yes
- No
If Yes, how many doses of the vaccine have you received thus far?
- One
- Two
- Three
Has it been more than 2 weeks since your most recent vaccination dose?
- Yes
- No

COVID-19 Symptoms Checklist
Do you have any new onset (or worsening) of any of the following symptoms?
Fever*
- Yes
- No
Cough*
- Yes
- No
Shortness of breath / difficulty breathing*
- Yes
- No
Runny nose*
- Yes
- No
Sore throat*
- Yes
- No
Chills*
- Yes
- No
Painful swallowing*
- Yes
- No
Nasal congestion*
- Yes
- No
Feeling unwell / fatigued*
- Yes
- No
Nausea / vomiting / diarrhea*
- Yes
- No
Unexplained loss of appetite*
- Yes
- No
Loss of sense of taste or smell*
- Yes
- No
Muscle / joint aches*
- Yes
- No
Headache*
- Yes
- No
Conjunctivitis (commonly known as pink eye)*
- Yes
- No

References & Resources

AB Gov Public Health and Disease Management Guidelines (Aug. 28, 2020)
AB Gov COVID-19 Daily Health Checklist (Adult + Child) (Dec. 2020)
AB Gov COVID-19 Relaunch Guidance for Screen-based Production Industry (June 12, 2020)
AB Gov COVID-19 Relaunch Guidance for Indoor Events (Nov. 2020)
AB Gov CMOH Record of Decision Order 42 (Dec. 11, 2020)
AB Gov Advanced Guidance Measures (Dec. 11, 2020)
AB Gov General Guidance Measures (evolving)

Creations
Clients
Curators
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