Kindergarten & Grade School Household Screening Agreement
To be completed upon request.

It is a requirement that you complete a self-assessment of any member(s) of your household who will be on campus at London Waldorf School prior to arriving at school each day.

Please read and sign this form to confirm that you will complete daily screening for you and your child(ren) using the criteria listed below. Additional guidance can be found through the use of the Ontario School Screening Tool available at  covid-19.ontario.ca/school-screening/

***Note: one form can be completed for all household members
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Last Name(s) *
First Name(s) *
At which screening station will you and/or your children be entering the school? *
QUESTION 1: Is the student/child currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you/they already have.
-Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

-Cough or barking cough (croup) - Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causes or conditions)

-Shortness of breath - Out of breath, unable to breath deeply (not related to asthma or other known causes or conditions)

-Decrease or loss of taste or smell - Not related to seasonal allergies, neurological disorders, or other known causes or conditions

-Nausea/vomiting and or diarrhea - Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions

If you answered “YES” to any of the symptoms included under question 1, do not go to school or child care.
The student/child must isolate (stay home) and not leave except to get tested or for
a medical emergency.
• Talk with a doctor/health care provider to get advice or an assessment, including if the
student/child needs a COVID-19 test.
ϕ Siblings or other people in your household must stay at home until the student/child
showing symptoms tests negative, or is cleared by your public health unit, or is diagnosed
with another illness. Household members who are fully vaccinated or previously positive for
COVID-19 in the last 90 days and have since been cleared are not required to stay home.
• Contact your school/child care provider to let them know about this result.
I have read and understand the criteria for Question 1 *
QUESTION 2: Did the student/child receive their final (or second in a two-dose series)COVID-19 vaccination dose more than 14 days ago, or have they tested positive for COVID-19 in the last 90 days and have since been cleared?
If YES, skip questions 3, 4, 5.
I have read and understand the criteria for Question 2 *
QUESTION 3: Is someone that the student/child lives with currently experiencing any newCOVID-19 symptoms and/or waiting for test results after experiencing symptoms?
If the individual experiencing symptoms received a COVID-19 vaccination in the last
48 hours and is experiencing mild fatigue, muscle aches, and/or joint pain that
only began after vaccination, select “No.”
If you answered “YES” to question 3, do not go to school or child care.
• The student/child must isolate (stay home) and not leave except to get tested or for a
medical emergency.
• The student/child can return to school or child care after the individual with symptoms tests
negative, is cleared by your local public health unit, or is diagnosed with another illness.
• Contact your school/child care provider to let them know about this result.
I have read and understand the criteria for Question 3 *
QUESTION 4: In the last 10 days, has the student/child been identified as a “close contact” of someone who currently has COVID-19?
If public health has advised you that you do not need to self-isolate, select “No."
If you answered “YES” to question 4, do not go to school or child care.
• The student/child must isolate (stay home) for 10 days and not leave except to
get tested or for a medical emergency.
• Talk with a doctor/health care provider to get advice or an assessment, including if they
need a COVID-19 test. The student/child can only return to school/child care after 10 days,
even if they get a negative test result, as long as they do not develop any symptoms.
ϕ Siblings and other people in your household can go to school, child care or work, but must
not leave the home for other non-essential reasons. Household members who are fully
vaccinated or previously positive for COVID-19 in the last 90 days and have since been
cleared are not required to stay home.
• If the student/child develops symptoms or tests positive, contact your local public health
unit or doctor/health care provider for more advice.
• Contact your school/child care provider to let them know about this result.
I have read and understand the criteria for Question 4 *
QUESTION 5: In the last 10 days, has the student/child received a COVID Alert exposure notification on their cell phone?
If they already went for a test and got a negative result, select “No."
If you answered “YES” to question 5, do not go to school or child care.
• The student/child must isolate (stay home) and not leave except to get tested or for a
medical emergency.
• Visit an assessment centre to get them a COVID-19 test.
ϕ If they test negative (they do not have the virus), they can return to school/child care. ϕ If they test positive (they have the virus), they need to continue isolating and can return
only after they are cleared by your local public health unit.
• If they develop symptoms, contact your local public health unit or doctor/health care provider
for more advice.
ϕ Siblings or other people in your household can go to school, child care or work, but must
not leave the home for other, non-essential reasons until the individual who got the COVID
alert tests negative, or is cleared by your local public health unit. Household members who
are fully vaccinated or previously positive for COVID-19 in the last 90 days and have since
been cleared are not required to stay home.
• Contact your school/child care provider to let them know about this result.
I have read and understand the criteria for Question 5 *
QUESTION 6: In the last 14 days, has the student/child travelled outside of Canada AND:• been advised to quarantine as per the federal quarantine requirements AND/OR• is the student/child under the age of 12 and not fully vaccinated?
If travel was solely due to a cross border custody arrangement, select “No."
If you answered “YES” to question 6, do not go to school or child care
• The student/child must follow federal guidelines for individuals who have travelled
internationally, including not going to school/child care for 14 days after their arrival and
getting tested as per federal requirements.
• If the student/child has been directed to quarantine, they must stay home for 14 days and
not leave except to get tested or for a medical emergency. For more information on federal
requirements for travellers, please see the Government of Canada’s website.
• If the student/child develops symptoms and/or tests positive, contact your local public
health unit or doctor/health care provider for more advice.
• Contact your school/child care provider to let them know about this result.
I have read and understand the criteria for Question 6 *
QUESTION 7: Has a doctor, health care provider, or public health unit told you that the student/child should currently be isolating (staying at home)?
This can be because of an outbreak or contact tracing.
If you answered “YES” to question 7, do not go to school or child care.
• The student/child must isolate (stay home) and not leave except to get tested or for a
medical emergency.
• Follow the advice of public health. The student/child can return to school/child care after
they are cleared by your local public health unit.
• If the student/child develops symptoms, contact your local public health unit or
doctor/health care provider for more advice.
ϕ Siblings or other people in your household must stay at home until the student/child
tests negative, or is cleared by your public health unit. Household members who are fully
vaccinated or previously positive for COVID-19 in the last 90 days and have since been
cleared are not required to stay home.
• Contact your school/child care provider to let them know about this result.
I have read and understand the criteria for Question 7 *
QUESTION 8: In the last 10 days, has the student/child tested positive on a rapid antigen test or a home-based self-testing kit?
If the student/child has since tested negative on a lab-based PCR test, select “No."
If you answered “YES” to question 8, do not go to school or child care.
• The student/child must isolate (stay home) and not leave except to get tested or for a
medical emergency.
• Visit an assessment centre to get them a COVID-19 test.
ϕ If they test negative (they do not have the virus), they can return to school/child care. ϕ If they test positive (they have the virus), they need to continue isolating and can return
only after they are cleared by your local public health unit.
• If they develop symptoms, contact your local public health unit or doctor/health care provider
for more advice.
• Siblings or other people in your household must isolate until the individual who tested positive
on the rapid antigen test or home-based self-testing kit tests negative on a PCR test or is
cleared by the local public health unit. Household members who are fully vaccinated or
previously positive for COVID-19 in the last 90 days and have since been cleared are not
required to isolate.
• Contact your school/child care provider to let them know about this result
I have read and understand the criteria for Question 8 *
When completing screening each morning, if you answered “NO” to all questions, your child may go to school/child care. You will be asked to verify that you have completed your daily screening each day upon arrival at school for the first 2 weeks of the school year.
As per regular protocols, all sick individuals with any symptoms of illness should stay home, and
seek assessment from their regular health care provider if required. Individuals with severe symptoms
requiring emergency care should go to their nearest emergency department. If an individual develops
symptoms outside of the list above, the Public Health Unit may recommend other measures including
testing based on an assessment of the individual’s symptoms and exposure history.
By completing this form and typing my name below, I hereby agree to complete a daily household assessment prior to arriving at school in accordance with the questions laid out in this form and any current guidelines of the Middlesex London Health Unit. *
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