COVID-19 Screening Questions

Every employee, parent/caregiver, child or essential visitor must be screened for symptoms of ill health before entering the child care setting. Any adult dropping off the child must also pass screening even if they do not enter the building.

If the answer is yes to any of the questions, the child or adult has not passed screening and must not come to the nursery school.

Date:

Your Names:

Name of Adult (Last Name, First Name):



Name of Child (Last Name, First Name):

Close contact with a confirmed or presumptive case of COVID-19?

You
Yes No

Your Child
Yes No

Travel Outside of Canada in the last 14 days?

You
Yes No

Your Child
Yes No

If Yes where:

You


Your Child

Close unprotected contact with a person with respiratory illness?

You
Yes No

Your Child
Yes No

New or worsened cough or difficulty breathing or swallowing?

You
Yes No

Your Child
Yes No

New or worsened runny nose, sneezing, congestion or hoarse voice?

You
Yes No

Your Child
Yes No

Diarrhea?

You
Yes No

Your Child
Yes No

Sore Throat?

You
Yes No

Your Child
Yes No

New olfactory or taste disorder, nausea or vomiting?

You
Yes No

Your Child
Yes No

Fever? (greater than 37.8 C or 100 F must be excluded.) Record temp in comment box below.

You
Yes No

Your Child
Yes No

Onset date of first symptom (YY/MM/DD):

You


Your Child

Comments
(Please record temperature reading and any other comments):


What is 9 + 3? (Please answer to help us prevent spam)