Child/Staff/Visitor Covid-19 screening and attendance

Date *

Date

The information provided on this form is for *

A child A staff A visitor

Child/Staff/Visitor Name *

First Name Last Name

If you are not a child in care at Educara, or a regular staff member, please provide your email address and phone number so you can be reached at for contact tracing

example@example.com

If you are not a child in care at Educara, or a regular staff member, please provide details (Grandparent, Maintenance, V!va Staff, Parent Tour etc)

Phone Number

Area Code Phone Number

Time In *

: Hour Minutes AM/PM Option

Time Out *

: Hour Minutes AM/PM Option

Parents/staff/Visitor will record their temperature here *

1. Does your child have any of the following new or worsening symptoms? Symptoms should not be chronic or related to other known causes or conditions.

Fever and/or chills(temperature of 37.8°C/100.0°F or greater) *

Yes No

Cough (more than usual if chronic cough) including croup (barking cough, making a whistling noise when breathing)Not related to other known causes or conditions (e.g., asthma, reactive airway) *

Yes No

Shortness of breath (dyspnea, out of breath, unable to breathe deeply, wheeze, that is worse than usual if chronically short of breath). Not related to other known causes or conditions (e.g., asthma) *

Yes No

Decrease or loss of smell or taste (new olfactory or taste disorder)Not related to other known causes or conditions (e.g., nasal polyps, allergies, neurological disorders)? *

Yes No

2. Does your child have any of the following new or worsening symptoms? Symptoms shouldnot be chronic or related to other known causes or conditions.

Sore throat (painful swallowing or difficulty swallowing)Not related to other known causes or conditions (e.g., post nasal drip, gastroesophageal reflux) *

Yes No

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) *

Yes No

Headache that is new and persistent, unusual, unexplained, or long-lasting. Not related to other known causes or conditions (e.g., tension-type headaches, chronic migraines) *

Yes No

Nausea, vomiting and/or diarrhea. Not related to other known causes or conditions (e.g. transient vomiting due to anxiety in children, chronic vestibular dysfunction, irritable bowel syndrome, inflammatory bowel disease, side effect of medication) *

Yes No

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. Not related to other known causes or conditions (e.g., depression, insomnia, thyroid dysfunction, anemia) *

Yes No

3. Has your child travelled outside of Canada in the past 14 days? *

Yes No

4. Has your child been identified as a close contact of someone who is confirmed as havingCOVID-19 by your local public health unit (or from the COVID Alert app if they have their own phone)? *

Yes No

5. Has your child been directed by a health care provider including public health official to isolate? *

Yes No

Results of Screening Questions:

If you answered “YES” to any of the symptoms included under question 1:

- Your child should stay home to isolate immediately.

- Contact your child’s health care provider for further advice or assessment, including if yourchild needs a COVID-19 test or other treatment.

If you answered “YES” to only one of the symptoms included under question 2:

- Your child should stay home for 24 hours from when the symptom started.

- If the symptom is improving, your child may return to school/child care when they feelwell enough to do so. A negative COVID-19 test is not required to return.

- If the symptom persists or worsens, contact your child’s health care provider for furtheradvice or assessment, including if your child needs a COVID-19 test or other treatment.

If you answered “YES” to two or more of the symptoms included under question 2:

- Your child should stay home to isolate immediately.
- Contact your child’s health care provider for further advice or assessment, including if yourchild needs a COVID-19 test or other treatment.

If the individual answers “YES” to question 3, 4 or 5

- Your child should stay home to isolate immediately and follow the advice of public health.

- If your child develops symptoms, you should contact your local public health unit or thehealth care provider for further advice.

Parent/Guardian sign off *

Clear

Sign off for self screening (Over 18 adult)

Clear