LSDM COVID-19 Self Screening Questionnaire (Parents/Guardians/Visitors/Employees)

1
Name* This field is required.
First Name
Last Name
2
I am taking this screening as a:
Parent/guardian on behalf of a student/child
Employee
Visitor
3
Do any of the following apply to you?
YES
I am fully vaccinated against COVID-19 (it has been 14 days or more since your final dose of either a two-dose or a one-dose vaccine series)
I have tested positive for COVID-19 in the last 90 days (and since been cleared)
I am fully vaccinated against COVID-19 (it has been 14 days or more since your final dose of either a two-dose or a one-dose vaccine series)
I have tested positive for COVID-19 in the last 90 days (and since been cleared)
YES
YES
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4
In the last 14 days, have you travelled outside of Canada?
YESNO
5
In the last 14 days, have you travelled outside of Canada and been told to quarantine (per the federal quarantine requirements)?
YESNO
6
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?This can be because of an outbreak or contact tracing.
YESNO
7
In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?If public health has advised you that you do not need to self-isolate, select “No.”
YESNO
8
In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?If you already went for a test and got a negative result, select “No.”
YESNO
9
The symptoms listed in this section are the symptoms most commonly associated with COVID-19.
Our guidelines for children and adults continue to evolve as we learn more about
COVID-19, how it spreads, and how it affects people in different ways.
Choose any/all that are new, worsening, and not related to other known causes or
conditions you already have.
10
Are you currently experiencing any of these symptoms?Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.
Yes
Fever and/or chills
Cough
Shortness of breath
Decrease or loss of taste or smell
Nausea, vomiting, and/or diarrhea
Fever and/or chills
Cough
Shortness of breath
Decrease or loss of taste or smell
Nausea, vomiting, and/or diarrhea
Yes
Yes
Yes
Yes
Yes
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11
In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit?If you have since tested negative on a lab-based PCR test, select "No."
YESNO
12
Next Steps:You must isolate (stay home) except for a medical emergency and follow public health guidelines in order to return to class.
13
You can enter the school.If you feel sick or not well (not related to getting a COVID-19 vaccine in the last 48 hours), please stay home. Talk with a doctor if necessary.
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