Screening Questionnaire

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

Initial Screening Questions:

Age*
- UNDER 18
- 18 YEARS AND OLDER

COVID-19 ALBERTA HEALTH (FOR CHILDREN UNDER 18)
1. Has the child:
Traveled outside Canada in the last 14 days?*
- YES
- NO
Had close contact with a case of COVID-19 in the last 14 days?*
- YES
- NO
2. Does the child have any new onset (or worsening) of the following core symptoms:
Fever*
- YES
- NO
Cough*
- YES
- NO
Shortness of breath*
- YES
- NO
Loss of sense of smell or taste*
- YES
- NO
3. Does the child have any new onset (or worsening) of the following other symptoms:
Chills*
- YES
- NO
Sore throat/painful swallowing*
- YES
- NO
Runny nose/congestion*
- YES
- NO
Feeling unwell/fatigued*
- YES
- NO
Nausea, vomiting and/or diarrhea*
- YES
- NO
Unexplained loss of appetite*
- YES
- NO
Muscle/joint aches*
- YES
- NO
Headache*
- YES
- NO
Conjunctivitis (commonly known as pink eye)*
- YES
- NO
COVID-19 ALBERTA HEALTH DAILY CHECKLIST (FOR ADULTS 18 YEARS AND OLDER)
Does the attendee 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 / Nasal Congestion:*
- 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
2-Has the attendee travelled outside Canada in the last 14 days?*
- YES
- NO
3-Has the attendee had close contact1 with a case of COVID-19 in the last 14 days?*
- YES
- NO
- 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 Information
Child's Name*
First Last
Drop-off Time*
Pick-up Time*
Your Name*
First Last
Signature*
Date : 22/01/2021