Family Screening Survey

Daily Family Screening Survey

You must fill out one survey for each child attending the program. Parent /guardian will be asked these questions daily at drop off and the temperature of your child(ren) and parent /guardian will be recoded daily.

1. Do you, your child or anyone residing in your household have any of the possible COVID-19 symptoms below?

a) Fever (37.8C or higher)
b) Cough (new or worsening)
c) Difficulty Breathing/Shortness of Breath (unable to breathe deeply)
d) Abdominal Pain
e) Diarrhea
f) Nausea/Vomiting
g) Pink Eye (conjunctivitis)
h) Decrease or loss of sense of smell/taste
i) Runny Nose (not related to seasonal allergies or other known cause/condition)
j) Nasal Congestion (not related to seasonal allergies or other known cause/condition)
k) Unexplained fatigue/malaise
l) Headaches
m) Infants/Young Children-sluggishness or lack of appetite

YES     NO

2. To the best of your knowledge has anyone that has had direct contact with you, your child or anyone residing in your household travelled outside of Canada in the last 14 days?

YES     NO

3. In the last 14 days have you had contact with a confirmed or probable case of COVID19?

YES     NO

By signing below, you are confirming that your child does not have any of the above symptoms or have been in contact with someone that has travelled. I understand it is my responsibility to inform the program Supervisor/designate immediately if any of the above responses change.

Parent/Guardian Signature and Print ___________________________________________________________________________________________________________________