COVID-19 Child Screening Form
(Updated April 19, 2021)
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Student's name: *
Location / Class: *
Instructions for Questions 1. A) and 1. B)

* Use 5 days: If the person is fully vaccinated or 11 years or younger.

* Use 10 days: If they are 12 years or older and not fully vaccinated; or immune compromised.

* If the symptom is from a known health condition that gives them the symptom, select “No”. If the symptom is new, different or getting worse, select “Yes”.

* If there is mild tiredness, sore muscles or joints within 48 hours after a COVID-19 vaccine, select “No”.
If longer than 48 hours, select “Yes.”

* Anyone who is sick or has any symptoms of illness, should stay home and seek assessment from their health care provider if needed.
1. Do you or anyone in the household have 1 or more of these new or worsening symptoms, today, or in the last 5 or 10 days*? *
If "YES": Stay home & self-isolate. Your household including siblings must self-isolate, regardless of vaccination status.
Yes
No
Fever > 37.8°C and/or chills
Cough
Difficulty breathing
Decrease or loss of taste/smell
2. Do you or anyone in the household have 2 or more of these new or worsening symptoms today, or in the last 5 or 10 days*? *
If "YES": Stay home & self-isolate. Your household including siblings must self-isolate, regardless of vaccination status. Note: If child/student has 1 of these symptoms, stay home until symptoms improve for at least 24 hours - or 48 hours if nausea/vomiting/diarrhea.
Yes
No
Sore throat
Headache
Feeling very tired
Runny nose / nasal congestion
Muscle aches / joint pain
Nausea, vomiting or diarrhea
3. Have you or anyone in the household had a positive COVID-19 test in the last 5 or 10 days*,or been told to stay home and self-isolate? *
** Use 5 days: If the person is fully vaccinated or 11 years or younger. Use 10 days: If they are 12 years or older and not fully vaccinated; or immune compromised. *If you had a positive test or live with someone who is isolating or awaiting test results select “Yes” • If you had a confirmed COVID-19 infection within 90 days select “No”.
4. In the last 5 or 10 days* have you been notified as a close contact of someone with COVID-19 in the community? *
• If the person is not a household member AND you are fully vaccinated** OR had a confirmed COVID-19infection within 90 days*** select “No” • If the person was in the same classroom/school/child care cohort select “No”. If “YES”: Stay home & self-isolate.
5. In the last 14 days, have you travelled outside of Canada? *
Please note: Starting February 28th, 2022: If you qualify as a fully vaccinated traveller, your unvaccinated or partially vaccinated children will be exempt from quarantine, without any limitations on their activities. You are still required to wear a mask at all times when in public spaces (unless if under 2 years of age), including schools/childcare, and monitor for symptoms.
Parent's Initial: *
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