Child/Staff/Visitor Covid-19 screening and attendance

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

Does the child/staff/visitor, or anyone else in the same household, have any of the following symptoms: severe difficulty breathing (struggling for each breath, can only speak in single words):

• severe chest pain (constant tightness or crushing sensation)
• feeling confused or unsure of where you are
• losing consciousness
• fever (feeling hot to the touch, a temperature of 37.8 degrees Celsius or higher)
• chills
• cough that's new or worsening (continuous, more than usual)
• barking cough, making a whistling noise when breathing (croup)
• shortness of breath (out of breath, unable to breathe deeply)
• sore throat
• Clinical or radiological evidence of pneumonia
• difficulty swallowing
• runny, stuffy or congested nose (not related to seasonal allergies or other known causes or conditions)
• lost sense of taste or smell
• pink eye (conjunctivitis)
• headache that’s unusual or long lasting
• Exacerbation of chronic conditions
• digestive issues (nausea/vomiting, diarrhea, stomach pain)
• muscle aches
• extreme tiredness that is unusual (fatigue, lack of energy)
• falling down often
• for young children and infants: sluggishness or lack of appetite
• unexplained tachycardia, including age specific tachycardia for children
• decrease in blood pressure
• unexplained hypoxia (even mild)

Based on the question above select one of the following answers

Yes No

Has the child/staff/visitor, or a member of the household, traveled outside Canada in the last 14 days?

Yes No

Does the child/staff/visitor have a confirmed case of Covid-19, or has been in contact with a confirmed or probable case of Covid-19?

Yes No

Has the child/staff/visitor had close contact with anyone with an acute respiratory illness?

Yes No

Has the child/staff/visitor taken any fever reducing medication is last 8 hours?

Yes No

Does anyone in your house have a fever?

Yes No

Parent/Guardian sign off

Clear

Sign off for self screening (Over 18 adult)

Clear