IN-HOME Safety Protocol for Clients/TUTORS

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Client and Tutor HEALTH Declaration - It is recommended that the family complete a quick declaration form prior to EVERY tutoring session starting. The questionnaire only relates to new symptoms or a worsening of symptoms related to allergies, chronic or pre-existing conditions. Those with symptoms related to pre-existing conditions or allergies are okay.

Email *

Client Name *

Tutor Name *

Date of Tutoring Session *

YYYY

Has anyone in the house experienced any new onset (or worsening) of any of the following symptoms commonly associated with COVID-19: fever*, cough*, shortness of breath/difficulty breathing*, runny nose* sore throat*, chills, painful swallowing, nasal congestion, feeling unwell / fatigued, nausea/vomiting/diarrhea,unexplained loss of appetite, loss of sense of taste or smell, muscle/joint aches, headache, conjunctivitis (pink eye)? *

Yes

Has anyone in the home tested positive or presumptively positive for COVID-19 or been identified as a potential carrier of the COVID-19 virus? *

Yes

Is anyone in the house currently under quarantine order? * *

Yes

Is anyone living in the home had close contact with an individual who has any one of the first 5 symptoms on this list(*) fever, cough, shortness of breath, runny nose or sore throat AND who is a close contact of a confirmed case of COVID-19 in the last 14 days? *

Yes

Have you or any member of your household traveled outside of Canada (including USA) in the last 14 days? *

Yes

If you, the family have answered “Yes” to any of the above questions, our tutor will NOT enter the home for the tutoring sessions. The best plan of action is to continue with online/virtual support. If you, the clients have answered “No” to all the above questions, you are allowed to have in-person session today. Please sign the document below everytime. Our goal is to minimize the risk of infection to our tutors, students and families. Thank you for your understanding and cooperation. If a family is unwilling to complete the form, the tutor or the local office reserves the right to cancel the session and follow our local cancellation policies. *

Please check box if you have read and understood this

Required

Signature of Parent / Guardian / Mature Student (type in name) *

Signature of Tutor (type in name) *

Send me a copy of my responses.

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