Child Daily Screening Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete each day before arriving at the centre.

Email *

Child’s Name *

Today’s Date *

YYYY

1. Does your child have any of the following new or worsening symptoms? Fever (>37.8 degrees Celsius), cough, difficulty breathing, or loss of taste or smell? If “YES”:Stay home, self-isolate & get tested or contact your child’s health care provider. *

Yes

Required

2. Does your child have any of the following new or worsening symptoms? Sore throat, painful swallowing, stuffy/runny nose, headache, nausea, vomiting, diarrhea, feeling unwell, muscle aches, feeling tired? If “YES” to ONE symptom: Stay home for 24hrs from when symptom started. If improving after 24hrs, child may return to child care. No test needed. If not improving, or getting worse, self-isolate & get tested. If “YES” to TWO or more symptoms: stay home, self-isolate & get tested or contact your child’s health care provider. *

Yes to one symptom

Yes to two or more symptoms

Required

3. Has your child travelled outside Canada in the past 14 days? *

Yes: Your child must stay home, self-isolate & follow the advice of public health.

Required

4. Has your child been identified as a close contact of someone with COVID-19? *

Yes: Your child must stay home, self-isolate & follow the advice of public health.

Required

5. Has your child been instructed to stay home and self-isolate? *

Yes: Your child must stay home, self-isolate & follow the advice of public health.

Required

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms