COVID-19 Screening & Tracking Form

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We require this form to be filled out prior to anyone entering the building.

All parents will be asked the following questions for themselves & their children.

Email *

Name *

Phone number

1: Are you experiencing any of the following symptoms? *

Fever (37.8 degrees Celsius or greater)

New or worsening cough

New or worsening shortness of breath

Difficulty breathing

Sore throat

Difficulty swallowing

Decrease or loss of taste or smell

Chills

Headaches

Unexplained fatigue / muscle soreness / pain / myalgia

New or worsening digestive symptoms, including nausea, vomiting, diarrhea, & or abdominal pain

Pink eye / Conjunctivitis

Runny nose, or nasal congestion - without other known cause

None of the above

Required

2: Have you tested positive for COVID-19 in the last 14 days? *

Yes

3: Is anyone you live with or your close contacts currently experiencing any COVID-19 symptoms & / or waiting for test results? *

Yes

4: Has a doctor, health care provider or public health unit told you that you should currently be isolating (staying at home)? *

Yes

5: In the last 14 days have you or someone in your household travelled outside of Canada & been told to quarantine (per the federal government requirements)? *

Yes

COVID-19 Screening Results

If response to all the screening questions is NO - COVID-19 Screen Negative

If response to any of the screening questions is YES - COVID-19 Screen Positive

COVID-19 Screen Positive: Student will be sent home & we recommend a 2-week quarantine & COVID-19 test.

Date:

YYYY

A copy of your responses will be emailed to the address you provided.

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