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 August 30th 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?*

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

3. Did you or your child receive your final (or second in two-dose series) COVID-19 vaccination dose more that 14 days ago, or have you tested positive for COVID-19 in the last 90 days and have since been cleared?*

Yes
No

If YES, skip questions 4, 5 and 6

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

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*