COVID-19 Daily Screening Questionnaire

1
Today's Date* This field is required.
Date
Day
Month
Year
2
Time of Screening* This field is required.
12
1
2
3
4
5
6
7
8
9
10
11
12
Hour
12
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
PM
AM
PM
3
Name of Child* This field is required.
Last Name
First Name
4
What room is your child attending?* This field is required.
Junior Room (School Age)
Buds & Blossoms (Preschool)
Sprouts (Toddler)
Seedlings (Toddler)
Sweet Peas (Infant)
5
Temperature Reading in Celsius* This field is required.
6
Time of Temperature Reading this morning?* This field is required.
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
AM
AM
7
Does your child or any person living in your household have any of the following new or worsening symptoms? Please check all that apply* This field is required.Screening Section One
Fever and/or chills (temperature of 37.8°C/100.0°F or greater)
Cough including croup (barking cough, making a whistling noise when breathing)
Shortness of breath (out of breath, unable to breathe deeply)
Decrease or loss of smell or taste (new olfactory or taste disorder)
None of the above
8
Has this child taken any over the counter or prescription fever reducing medication in the past 24 hours such as Advil, Motrin, Tylenol, Tempra etc?* This field is required.
YESNO
9
Does your child or any person living in your household have any of the following new or worsening symptoms? Please indicate the number of symptoms that your child or another household member currently has from this list.* This field is required.1. Sore throat (painful swallowing or difficulty swallowing) 2. Stuffy nose and/or runny nose (nasal congestion and/or rhinorrhea) Not related to other known causes or conditions (e.g. seasonal allergies, returning inside from the cold, chronic sinusitis unchanged from baseline, reactive airways) 3. Headache that is new and persistent, unusual, unexplained, or long-lasting 4. Nausea, vomiting and/or diarrhea 5.Fatigue, lethargy, muscle aches or malaise (general feeling of being unwell, lack of energy, extreme tiredness, poor feeding in infants) that is unusual or unexplained
None at this time
One or more symptom from this list
10
Has your child traveled outside of Canada in the past 14 days?* This field is required.Screening Section Two Part B
YESNO
11
Has your child been identified as a close contact of someone who is confirmed as having COVID-19 by your local public health unit (or from the COVID Alert app if they have on their own phone)??* This field is required.Screening Section Two Part B
YESNO
12
Has your child been directed by a health care provider including public health official to isolate?* This field is required.Screening Section Two Part B
YESNO
Should be Empty:

Save your progress

Save your progress

Your form submission has been saved as a draft.

Save your progress

Your form submission has been saved as a draft.