Active Screening Questionnaire for children in recreation programs.

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Active Screening is a health review of your child. Completing Active Screening daily BEFORE participation in a recreational program is a mandate of the Ministry of Health and Ottawa Public Health. Submitting this Questionnaire to the Manor Park Community Council (MPCC) makes it easy for you to comply.

It helps everyone remain safe and healthy!

Information collected will only be used by the Manor Park Community Council for the administration and management of 'Afternoons in the Park', as well as arts and sports programming. Information will only be shared as legally required.

Child's Name *

Does your child have one or more of the following symptoms? Check all that apply. Those who have one or more symptom will not be able to attend the program or enter the facility. *

Fever (37.8 degrees C or higher)

Cough that's new or worsening (continuous, more than usual)

Barking cough, making a whistling noise when breathing (croup)

Shortness of breath (unable to breathe deeply or feeling unable to catch one's breath)

Lost sense of taste or smell

None of the above

Required

Has your child been in close physical contact with a person who has tested positive for Covid-19 in the past 14 days? (Close contact means: living in the same home; OR being less than 2m away in the same room; OR unprotected contact for 15 minutes or longer.) *

Yes

Has your child been in close physical contact with a person who has returned from outside of Canada in the past 2 weeks with 'Covid-like' symptoms? *

Yes

Have your child's household contacts (family, roommates) or other contacts outside of school or child care presented with Covid-19 symptoms in the last 14 days? *

Yes

Notice of Risk from Ottawa Public Health:

When children from multiple families attend a recreational program, there is an increased risk of the Covid-19 virus coming into the program. Children who are infected with the Covid-19 virus are more likely than adults to have very mild infections or to have no symptoms at all, but these children can still transmit the infection to other children and to adults. This means that children can bring home an infection acquired in a recreational program and put other persons at risk. Even if a program has a screening process to help detect infections when there are symptoms, this screening process will not detect infected children or adults who do not have symptoms at the time of screening.

I have knowledge of this child's health and attest that the information provided is true. *

Yes

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