Pre-Lesson COVID-19 Screening Questionnaire

Prior to each driving lesson, the Coach will ask the student to verbally complete the following questionnaire to ensure it’s safe to proceed with the driving lesson.

COVID-19 Pre-Lesson Safety Questionnaire

To reduce sharing of objects and documents, Driving Coaches verbally administer this questionnaire and record the student’s responses.

Student Name:_____________________________________ Date:_________________

Please circle the student’s answer to the following questions:

  1. Are you feeling well with no symptoms of illness (COVID or otherwise)?    Y       N
  2. Do you have a fever?   Y       N
  3. Have you been in close contact with anyone who may have contracted COVID-19?    Y       N
  4. Have you travelled outside Canada within the last 14 days?   Y       N
  5. Do you have a mask to wear during your lesson?   Y       N    (if no, coach will provide)
  6. Do you understand that participating in a driving lesson will put you inside of the 2M social distancing recommendation?   Y       N
  7. Are you aware that you may choose to postpone your driving lesson if you have any concerns about participating today?   Y       N
  8. Do you understand the coach is authorized to end this lesson if questions about your health condition arise during this time?   Y       N
  9. The Coach will now ask the student if they agree with the following statement and record their response: “I have answered the questions truthfully and to the best of my knowledge there is no reason why I should not participate in a driving lesson today. I understand I am able to reschedule this lesson if I choose to do so.”         “I Agree”     “Other…” (lesson will be rescheduled)

This questionnaire will be held on file as record of the student’s participation in the lesson.

Coach Name:__________________________________________________

Coach Signature:_______________________________________________

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