LWS Faculty Screening Agreement

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To be completed each Sunday.

It is a requirement that you complete a self-assessment before arriving at London Waldorf School each day.

Please read and sign this form weekly to confirm that you will complete daily screening and to ensure you are aware of the questions required. Additional guidance can be found through the use of the Ontario School Screening Tool available at covid-19.ontario.ca/school-screening/

Upon arrival at the screening station at the beginning of the week, we will verify that we have a record of this attestation. If one has not been completed, a paper copy will be available to be completed at that time.

We will also confirm your self-assessment results daily.

Your Last Name *

Your First Name *

At which screening station will you be entering the school? *

Front Doors

Lower Parking Lot

QUESTION 1: In the last 14 days, have you travelled outside of Canada? If exempt from federal quarantine requirements, select "No" *

Yes

QUESTION 2: Has a doctor, health care provider, or public health unit told you that you should currently be isolating(stay at home)? This can be because of an outbreak or contact tracing. *

Yes

QUESTION 3: In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19? *

Yes

QUESTION 4: In the last 14 days have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No". *

Yes

QUESTION 5: Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening and not related to other known causes or conditions you 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, COPD, or other known causes or conditions you already have)

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

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

Sore throat - Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have

Difficulty swallowing - Painful swallowing (not related to other known causes or conditions you already have)

Runny or stuffy/congested nose - Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have

Pink eye - Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)

Digestive issues like nausea/vomiting, diarrhea, stomach pain - Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have

Falling down often - For older people

None of the above

Required

QUESTION 6: Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have. *NOTE: If you received a COVID-19 vaccination in the last 48 hours and are experiencing a mild symptoms from this list that only began after vaccination, do not check the symptom box. *

Headache - Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)

Muscle aches - Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have)

Extreme tiredness - Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

None of the above

Required

QUESTION 7: Is anyone you live with currently experiencing any new COVID-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 headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select "No." *

Yes

If you answered "YES" to questions 1 or 3 do not go to school or child care.

You must isolate (stay home) for 14 days and not leave except to get tested or for a medical emergency.
•
If you answered “YES” to question 1, follow the advice of public health. You can return to school/child care after you are cleared by your local public health unit.
•
If you answered “YES” to question 3, talk with a doctor/health care provider to get advice or an assessment, including if you need a COVID-19 test. You can return to school/child care only after 14 days, even if you get a negative test result.
•
If you develop symptoms, contact your local public health unit or doctor/health care provider for more advice.

If you answered "YES" to question 2 do not go to school or child care.

You must self-isolate (stay home) and not leave except for a medical emergency.
•
Follow the advice of public health. You can return to school/child care after you are cleared by your local public health unit.
•
If you develop symptoms, contact your local public health unit or doctor/health care provider for more advice.

If you answered "YES" to question 4 do not go to school or child care.

You must self-isolate (stay home) and not leave except for a medical emergency.
•
Visit an assessment centre to get a COVID-19 test.
∙
If you test negative (you do not have the virus), you can return to school/child care.
∙
If you test positive (you have the virus), you can return only after you are cleared by your local public health unit.
•
If you develop symptoms, contact your local public health unit or doctor/health care provider for more advice.
•
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 you test negative or are cleared by your local public health unit.

If you answered "YES" to any of the symptoms included under questions 5 or 6, or "YES" to question 7 do not go to school or child care.

The household must self-isolate (stay home) and not leave except to get tested or for a medical emergency.
•
If you answered “YES” to question 5 or 6, talk with a doctor/health care provider to get advice or an assessment, including if the student/child needs a COVID-19 test.
•
If you answered “YES” to question 7, the student/child can return to school/child care after the individual gets a negative COVID-19 test result, or is cleared by your local public health unit, or is diagnosed with another illness.
•
Siblings or other people in your household must stay at home until you or the individual gets a
negative COVID-19 test result, or are cleared by your local public health unit, or are
diagnosed with other illness.

If you answered “NO” to all questions, your child may go to school/child care because they seem to be healthy and have not been exposed to COVID-19.

If the you has received a COVID-19 vaccination in the last 48 hours and have mild headache, fatigue, muscle aches and/or joint pain that only began after immunization, and no other symptoms, you are to wear a surgical/procedure mask for your entire time at school/child care. Your mask may only be removed to consume food or drink and you must remain at least two meters away from others when your mask has been removed. If the symptoms worsen, continue past 48 hours, or if you develop other symptoms, you should leave school immediately to self-isolate and seek COVID-19 testing.

I hereby agree to complete a daily assessment prior to arriving at school and will follow the guidelines and recommendations as set out in the Ontario COVID-19 School and Child Care Screening tool for employees. *

Yes

Required

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