COVID-19 Active Screening Form

*To be completed daily for each household (1 form for each child)

Instructions: These screening questions apply to everyone in the household and to child(ren) in child care. Temperature recordings are only required for those entering or residing in the home child care residence.

 

If YES was answered for any of the questions for the child attending childcare or any household member (parents/guardians, siblings), the Provider may not permit them to enter the centre.

 

Close contact is being coughed or sneezed on or within 2 meters of an individual with COVID-19 symptoms for 15 minutes.

Q1: Does anyone in your home have fever, new onset of cough, worsening chronic cough, shortness of breath or difficulty breathing, or any other symptoms below*?
Q2: Did your child(ren) or anyone in your home have close contact with anyone with fever, cough, shortness of breath or difficulty breathing in the last 14 days?
Q3: Did your child(ren) or anyone in your home have COVID-19 or had close contact with a confirmed or suspected case of COVID-19 in the last 14 days?
Q4: Does anyone in your home have a temperature of 37.8°C or higher?
Q5: Did your child(ren) or anyone in your home travel outside Ontario in the past 14 days?
Q6: Did any child(ren) experience unexplained lack of energy or difficulty feeding?

*Other Symptoms Include:

Sore throat, Difficulty swallowing, Pink eye (conjunctivitis), Nasal congestion or runny nose without other known cause, Rash (if a child), Croup (respiratory infection resulting in barking cough and difficulty breathing) (if a child), Unexplained fatigue/malaise/muscle aches, Diarrhea, Nausea/vomiting, Decrease or loss of sense of taste or smell, Chills, Headaches or Abdominal pain.

Thanks for submitting the daily COVID-19 Active Screening Form for Households