Wellness Survey Week Six

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This survey is to assist in determining the health and well-being of our class participants. Our goal is to minimize the risk of infection to our staff and children, thank you for your understanding and cooperation. If you have answered YES to any of the below questions, please DO NOT attend class today. If you have answered NO to all of the below questions, remember to sign in and out and practice hand hygiene (wash hands for 20 seconds, and/or use hand sanitizer) before and after you visit.

Do you, or your child attending the program, have any of the following below symptoms? *

Yes

Fever

Cough

Shortness of Breath / Difficulty Breathing

Chills

Painful swallowing

Runny Nose / Nasal Congestion

Feeling unwell / Fatigued

Nausea / Vomiting / Diarrhea

Unexplained loss of appetite

Loss of sense of taste or smell

Muscle / Joint Aches

Headache

Congunctivitis (Pink eye)

Has your child travelled outside of Canada in the last 14 days or has someone in the household travelled outside of Canada in the last 14 days and is ill? *

Yes

Have you or your children attending the program had close unprotected contact (face-to-face within 2 meters) in the last 14 days with someone who is ill with cough and/or fever? *

Yes

Have you or anyone in your household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?

Yes

Clear selection

Parent and/or Guardian Consent *

I acknowledge that the above information is as accurate and truthful as possible

Required

Child(ren) Name(s) *

Parent Name *

Date *

YYYY

Submit

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