COVID-19 Screening Assessment (NUF House North Inc.)

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*NOTE* When signing this form, you are asserting that the information is true and that you have personal knowledge of the facts contained in the form. By signing, you are also stating that you are competent to and that you are of sound mind and you are over the age of 18.

Please also note that parents are responsible for taking their childs temperature at home. Temperature will also be taken prior to entering the daycare.

Child's Full Name *

Program Room *

Toddler

Preschool

Kindergarten

Parent's Name *

Childs Temperature this morning *

1. In the last [5,10] days has the student/child experienced any of the following symptoms? (If yes, do not attend school or child care.) *If the student/child is fully vaccinated OR 11 years old or younger, isolate for 5 days. *If the student/child is 12 years of age or older and not fully vaccinated OR if they are immune compromised, isolate for 10 days. **Anyone who is sick or has any new or worsening symptoms of illness, including those not listed below should stay home until their symptoms are improving for 24 hours and should seek assessment form their health care provider if needed. Household members of individuals with any of the below symptoms should stay home at the same time as the person who is sick, regardless of vaccination status. *

Fever of 37 Degrees Celsius or greater and/or Chills

Cough or Barking Cough (Croup)

Shortness of Breath

Decrease or Loss of Taste or Smell

No Symptoms

Required

2. In the last [5,10] days has the student/child experienced any of the following symptoms? (If yes, do not go to school or child care) *If the student/child is fully vaccinated OR 11 years old or younger, isolate for 5 days *If the student/child is 12 years of age or older OR is not fully vaccinated OR if they are immune compromised, isolated for 10 days. *

Sore Throat

Headache

Extreme Fatigue

Runny Nose or Nasal Congestion

Muscle Aches or Joint Pain

Gastrointestinal Symptoms (ex. vomiting or diarrhea)

No Symptoms

Required

3. In the last [5,10] days has the student/child tested positive for COVID-19? (This includes a positive COVID-19 test result on a lab-based PCR test, rapid antigen test or home-based self-testing kit.) *

Yes; Do not go to school or child care. Self-isolate and only leave for a medical emergency. Isolate for 5 days (children under 11 years old) or 10 days (children older than 12 years and/or unvaccinated) from when symptoms started or when tested positive for COVID-19. Stay in isolation until symptoms have been improving for at least 24 hours, or 48 hours after symptoms of nauseam, vomiting and/or diarrhea, and do not have a fever.

Required

4. Does the student/child live with someone who is currently isolating because of COVID-19 test? Does the student/child live with someone who is currently isolating because of COVID-19 symptoms? Does the student/child live with someone who is currently isolating while waiting for COVID-19 test results? *

Yes; Do not go to school or child care. Self isolate while there is anyone in the home who is isolating because of symptoms of COVID-19, a positive COVID-19 test result, or is waiting for a COVID-19 test result. Only leave home for a medical emergency. All household members must stay home at the same time as the household member who has COVID-19 symptoms or is a positive COVID-19 case, whether they are fully vaccinated or not - unless they tested positive for COIVD-19 in the past 90 days and have already completed their isolation period. If another household member develops symptoms or tests positive, you must continue isolation until they have also finished their own isolation period. The initial household member(s) with symptoms and/or positive test results does not have to extend their isolation period based on other household members developing symptoms.

5. Has your child been identified as a "close contact" of someone who currently has COIVD-19 or has symptoms of COIVD-19 (any one or more symptoms from question s1 above or any two or more symptoms from questions 2)? *

Yes; Do not go to school or child care. Self isolate for 5 days (children under 11 years) and 10 days (children older than 12 years and/or unvaccinated). Only leave home to get tested or for a medical emergency. As long you and your household members do not develop any symptoms, other people in your household can go to school child care or work, but not leave the home for other non-essential reasons.

6. Has a doctor, health care provider, or public health unit told you that the student/child should currently be isolation (staying at home)? *

7. In the last 14 days, has the student/child travelled outside of Canada and was told to quarantine? In the last 14 days, has the student/child travelled outside of Canada and was told not to attend school/child care? In the last 14 days, someone the student/child lives with has returned from travelling outside of Canada and is isolating while awaiting results of a COVID-19 test? *

Yes; Do not go to school or child care. Follow Federal guidelines for individuals who have travelled internationally, including not going to school or child care for 14 days after their arrival and getting tested as per Federal requirements. If directed to quarantine, you must stay home for 14 days and do not leave home except to get tested or for a medical emergency. If someone you live with is isolating following return from travelling outside of Canada and received a take-home PCR test at the airport, is symptomatic follwing international travel OR is awaiting test results, you must stay home until the individual has received a negative PCR test result or has completed their isolation period. If you develop symptoms, you must also follow isolation guidance found under the results to questions 1 and 2.

Thank you for completing the assessment form!

Please visit york.ca/COVID19 and york.ca/SafeAtSchool for information on ways to protect yourself, your family and your school community. Stay Safe and Take Care!

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