Covid-19 Questionnaire

Name

First Name Last Name

1. Are you currently experiencing any of the symptoms?

Fever and/or Chills (temperature of 37.8 or higher) Cough or Barking Cough (continuous, more than usual, whistling noise while breathing) Shortness of Breath (out of breath, unable to breathe deeply) Decrease or Loss of Smell or Taste Sore Throat or Difficulty Swallowing (painful swallowing) Runny or Stuffy/ Congested Nose (not related to seasonal allergies) Headache that's Unusual or Long Lasting (not related to tension-type headaches, chronic migraines) Nausea, Vomiting, and/or Diarrhea (not related to irritable bowel syndrome, anxiety in children, menstrual cramps) None of the above

2. Have you travelled outside of Canada the last 14 days?

Yes No

3. In the last 14 days, has a public health unit identified them as a close contact of someone who currently has COVID-19?

Yes No

4. Has a doctor, health care provider, or public health unit told them/you that they should currently be isolating (staying at home)?

Yes No

5. In the last 14 days, have they received a COVID Alert exposure notification on their cell phone?

Yes No

Results of Screening Questions

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

Contact the school/child care to let them know about this result.
They should isolate (stay home) and not leave except to get tested or for a medical emergency.
Talk with a doctor/health care provider to get advice or an assessment, including if they need aCOVID-19 test.
Household members without symptoms may go to school/child care/work. Check your local public health unit’s website or call to see if they have di erent rules based on local risk.

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

Contact the school/child care to let them know about this result.
They should isolate (stay home) for 24 hours and not leave except for a medical emergency.
After 24 hours if their symptom is improving, they can return to school/child care when they feel well enough to go. They do not need to get tested.
Household members without symptoms may go to school/child care/work. Check your local public health unit’s website or call to see if they have di erent rules based on local risk.

If you answered “YES” to two or more of the symptoms included under question 1:

Contact the school/child care to let them know about this result.
They should isolate (stay home) and not leave except to get tested or for a medical emergency.
Talk with a doctor/health care provider to get advice or an assessment, including if they need aCOVID-19 test.
Household members without symptoms may go to school/child care/work. Check your local public health unit’s website or call to see if they have di erent rules based on local risk.

If you answered “YES” to question 3, 4, or 5:

Contact the school/child care to let them know about this result.
They should isolate (stay home) for 14 days and not leave except to get tested or for a medical emergency.
Talk with a doctor/health care provider to get advice or an assessment, including if they need aCOVID-19 test.

If you answered “NO” to all questions, your child may go to dance.

Covid-19 Questionnaire

Tick off the box below if they apply to you