SRCPC Covid-19 Screening Form

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Created Oct 28, 2020 for South Riverdale Child-Parent Centre's programming. When filling out this screening form, you are agreeing that this is true for yourself and all those attending the program with you.

Are you or your child currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or medical conditions. *

Fever and/or chills (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher)

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

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

Sore throat (Not related to other known causes or conditions (for example, seasonal allergies, acid reflux)

Difficulty swallowing (Painful swallowing, not related to other known causes or conditions)

Headache that’s unusual or long lasting (Not related to other known causes or conditions (for example, tension-type headaches, chronic migraines))

Digestive issues like nausea/vomiting, diarrhea, stomach pain (Not related to other known causes or conditions (for example, irritable bowel syndrome, menstrual cramps))

Muscle aches that are unusual or long lasting (Not related to other known causes or conditions (for example, a sudden injury, fibromyalgia))

Extreme tiredness that is unusual (Fatigue, lack of energy, not related to other known causes or conditions (for example, depression, insomnia, thyroid disfunction))

None of the above

Required

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? *

Yes

In the last 5 or 10 days have you been notified as a close contact of someone with COVID-19 in the community? *

Yes

For indoor program, please click here to confirm you are fully vaccinated ie. have received two doses of a recognized vaccine or the one dose of the Johnson & Johnson vaccine (For Adult Participants)

I Confirm

If you travelled outside of Canada in the last 14 days:

Follow federal requirements for quarantine and testing after returning from international travel

Name and Phone Number or Email *

Public Health Ontario - Contact Tracing

This information will only be used by Public Health officials for contact tracing. All information will be deleted in 30 days.

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