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Screening Questionnaire

PLEASE FILL OUT THIS QUESTIONNAIRE TO DECIDE IF YOU SHOULD ENTER TODAY

Initial Screening Questions:

1. Do you, or your child attending the program, have any of the below symptoms:
Fever:*
- YES
- NO
Cough:*
- YES
- NO
Shortness of Breath / Difficulty Breathing:*
- YES
- NO
Sore throat:*
- YES
- NO
Runny Nose / Nasal Congestion:*
- YES
- NO
Feeling unwell / Fatigued:*
- YES
- NO
Nausea / Vomiting / Diarrhea:*
- YES
- NO
Muscle Aches:*
- YES
- NO
Headache:*
- YES
- NO
Conjunctivitis:*
- YES
- NO
2. Have you or anyone in your household, travelled outside of Canada in the last 14 days?*
- YES
- NO
3.Have you or your children attending the program had close unprotected* contact (face-to-face contact within 2 meters/6 feet) with someone who is ill with cough and/or fever?*
- YES
- NO
4.Have you or anyone in your household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?*
- YES
- NO
* "unprotected" means close contact without appropriate personal protection equipment (PPE).
- If you have answered "Yes" to any of the above questions, please DO NOT enter at this time.
- If you have answered "No" to all the above questions, please sign in and out and practice hand hygiene (wash hands for 30 seconds, and or use hand sanitizer) before and after your visit.
- Our goal is to minimize the risk of infection to our staff and children, thank you for your understanding and cooperation.
Child's Name*
First Last
Drop-off Time*
Pick-up Time*
Your Name*
First Last
Email*
Signature*
Date : 03/06/2020

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