Earth Path Winter/Spring 2022 Nature School COVID-19 Pre-Screening
PLEASE READ BEFORE FILLING OUT SURVEY:

Staff, volunteers, participants, parents/guardians, visitors, or any other people who will be entering our program setting are required to self-screen or be screened for COVID-19 signs and symptoms prior to arrival at program.

Submit a screening survey for your household before you arrive to program each week. If you have someone doing drop-off or pick-up that is not a part of your household, they are required to fill out this form out separately in addition to yours. If you answer yes to any of the following questions, please do not attend program.

Thank you, and stay healthy!
Sign in to Google to save your progress. Learn more
Email *
COVID-19 Reference Document for Symptoms
http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_reference_doc_symptoms.pdf
Your name: *
Participants name(s): *
Has anyone in your household tested positive for COVID-19 in the past 5 days? *
In the last five days has anyone in your household experienced: shortness of breath or difficulty breathing, new or worsening cough, fever of 37.8 or higher, loss of taste or smell, muscle aches/joint pain, extreme fatigue, sore throat, headache, unexplained runny nose or congestion, nausea, vomiting, or diarrhea? *
If you answered YES to any of the above questions, we ask that you do not attend program today. We encourage testing where possible.
By typing your full name below, you confirm that all information provided in this form is accurate and true to the best of your knowledge: *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Weebly Email Service. Report Abuse
Google Forms