Daily Health Screening for Students

1
IMPORTANT INSTRUCTIONS

PLEASE NOTE: New questions have been added.

The following Daily Health Screening must be completed by a PARENT/GUARDIAN.

A separate form must be completed DAILY for EACH CHILD

The form must be completed, whether your child is coming to school today or not.

If you are keeping your child home due to COVID-19 related symptoms, you do not need to report the absence to the office, this form is sufficient.

If you are keeping your child home (or if your child will arrive late today) for ANY OTHER REASON, please contact the office: grayacademy@grayacademy.ca or 204-477-7410.
2
Parent/Guardian Name* This field is required.
First Name
Last Name
3
Child's Name* This field is required.
First Name
Last Name
4
Child's Grade (and Class for Elementary)* This field is required.
JKA (HaMorah Rachel)
JKB (HaMorah Silvina)
JKA/C (HaMorah Rachel & HaMorah Lauren)
JKB/C (HaMorah Silvina & HaMorah Lauren)
KA (HaMorah Erica & HaMorah Lainie)
KB (HaMorah Candace & HaMorah Erica)
1A (HaMorah Anna & HaMorah Tatyana)
1B (HaMorah Gabi & HaMorah Silvina)
2A (HaMorah Tatyana & HaMorah Anna)
2B (HaMorah Alexandra & HaMorah Gabi)
3A (HaMorah Amy & HaMorah Na'amaa)
3B (HaMorah Lauren & HaMorah Naama)
4A (HaMorah Na'ama & HaMorah Amy)
4B (HaMorah Naama & HaMoreh Chris)
5A (HaMorah Sharona & Ms. Vickar)
5B (HaMorah Aleksandra & HaMorah Candace)
6A (Ms.Vickar & HaMorah Sharona)
6B (Mrs.Pollock & HaMorah Sherry)
7
8
9
10
11
12
5
NEW: Has ANYONE in your household visited INDOORS at any private residence besides your own in the last 10 days (excluding for purposes exempted by public health)?* This field is required.
YESNO
6
NEW: has ANYONE who is not part of your household visited INDOORS at your residence in the last 10 days (excluding for purposes exempted by public health)?* This field is required.
YESNO
7
Has ANYONE in your household tested positive for COVID-19 in the past 14 days?* This field is required.
YESNO
8
Is ANYONE in your household awaiting results of a COVID-19 test?* This field is required.
YESNO
9
Has your child had fever and/or chills TODAY or YESTERDAY?* This field is required.
YESNO
10
Does your child have any of the following symptoms TODAY:* This field is required.New or worsening cough - unrelated to an ongoing condition such as asthma or allergies Difficulty Breathing - unrelated to an ongoing condition such as asthma or allergies
YESNO
11
Does your child have any of the following symptoms TODAY:* This field is required.Sore throat Hoarse voice Loss of sense of smell and/or taste
YESNO
12
Has your child had any of the following symptoms YESTERDAY or TODAY:* This field is required.Vomiting Diarrhea for more than 24 hours
YESNO
13
Does your child have any of the following symptoms TODAY:* This field is required.Runny nose Muscle pain (unrelated to injury) Unexplained fatigue Pink eye Headache Unexplained rash Nausea Loss of appetite
YESNO
14
Is ANYONE IN YOUR HOUSEHOLD showing symptoms related to COVID-19 (see previous screens)?* This field is required.
YESNO
15
In the past 14 days, has anyone in your household travelled outside of Manitoba (excluding those exempt from self-isolation as per current Manitoba Public Health orders)?* This field is required.
YESNO
16
Has anyone in your household been in close contact with a confirmed case of COVID-19 in the past 14 days OR been in a setting identified as high risk for acquiring COVID-19, such as a flight, workplace or event with a confirmed cluster of cases?* This field is required.
YESNO
17
Thank You

Thank you for completing today's Daily Health Screening. Please remember to hit SUBMIT in the bottom right corner to ensure we receive your information.
Should be Empty: