Required Covid-19 Screening – West Nipissing Child Care Corporation

Employees, providers, students, children and essential visitors in schools and child care settings.

Please note that the self-screening tool has been modified as of October 5th 2021.

The North Bay-Parry Sound District Health Unit has updated its “Schools/Child Care and COVID-19” information page.

Please answer the following questions: Check the appropriate box. Thank you.

1. I am taking this screening as a:*

Student/Child
Parent/Guardian on behalf of a student/child
Employee-Provider
Essential Visitor

2. Are you or your child currently experiencing any of these symptoms?*

The symptoms listed here are the symptoms most commonly associated with COVID-19.

If you have these symptoms, you should isolate and seek testing. Please note that rapid antigen testing is not to be used for those with symptoms of COVID-19 or for contacts of known COVID-19 cases.

Anyone who is sick or has any symptoms of illness, including those not listed below, should stay home and seek assessment from their health care provider if needed.

Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Fever and/or chills
Cough or barking cough (croup)
Shortness of breath
Decrease or loss of taste or smell
Tiredness
Muscle aches
None of the above

3. Do any of the following apply?*

• You are fully vaccinated against COVID-19 (it has been 14 days or more since your final dose of either a two-dose or a one-dose vaccine series)

• You have tested positive for COVID-19 in the last 90 days (and since been cleared)

If YES, skip questions 4, 5 and 6

Personal health information is not collected when you complete this screening tool. The purpose of this question is to provide accurate isolation instructions, which are based on vaccination status and previous infection history.

Yes
No

4. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

Children (<18 years old): fever and/or chills, cough or barking cough, shortness of breath, decrease or loss of taste or smell, nausea, vomiting and/or diarrhea.

Adults: (≥18 years old): fever and/or chills, cough or barking cough, shortness of breath, decrease or loss of taste or smell, tiredness, muscle aches.

If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing only mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”

Yes
No

5. In the last 10 days have you or your child been identified as a “close contact” of someone who currently has COVID-19?

Yes
No

6. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?

Yes
No

7. In the last 14 days, have you or your child under the age of 12 and not fully vaccinated travelled outside of Canada and been advised to quarantine as per federal quarantine requirements?*

Yes
No

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

Yes
No

9. In the last 10 days, have you or your child tested positive on a rapid antigen test or a home-based self-testing kit?*

Yes
No

If you have answered yes to any of the above questions or have refused to answer:

Your child will not be permitted to attend the child care center.

Please indicate which child care your child attends.*

La tanière des tout-petits
Service de garde des louveteaux
La niche des lionceaux
Centre-based
Home-Based Child Care
White Woods
La ruche des petites abeilles
EarlyON
Not applicable

Comments

By submitting this form I certify that the above statements are true and valid.

Name*

Date*

Phone*